Clinical Medical Review Nurse

Clinical Medical Review Nurse

We are seeking an experienced Clinical Medical Review Nurse to perform medical record reviews, data abstraction, and claims evaluation. This role supports pre- and post-claim medical reviews, ensures compliance with healthcare standards, and contributes to accurate claims adjudication across Commercial, FEP, and Medicare Advantage plans.

Key Responsibilities:

• Perform medical record abstraction by reviewing and extracting relevant clinical data.
• Conduct pre- and post-claim medical reviews to determine eligibility and benefits.
• Analyze provider appeals and clinical documentation for accuracy and compliance.
• Support HEDIS data collection and quality initiatives (training provided).
• Visit provider offices (minimum once a month) to retrieve medical records.
• Utilize EMR systems to review and document patient and claim information.
• Collaborate with internal teams to ensure accurate claims processing and adjudication.
• Maintain proper documentation and ensure adherence to medical policies and regulatory standards.

Required Skills:

• Active LPN or RN or Compact State License – MUST HAVE.
• Minimum 5+ years of clinical experience.
• Strong experience in medical record review and data abstraction – MUST HAVE.
• Hands-on experience with Electronic Medical Records (EMR) – MUST HAVE.
• Proficiency in Microsoft Excel (basic level) – MUST HAVE.
• Strong knowledge of clinical practices, claims review, or utilization review.
• Excellent communication, organizational, and analytical skills.

Preferred Skills:

• Experience with HEDIS measures and reporting.
• Background in case management, discharge planning, or utilization review.
• Bachelor's degree in Nursing or related field.

Lumen Solutions Group Inc is an equal opportunity employer. All qualified applicants will be considered for employment without regard to any legally protected status.