Health Services - Nurse, Clinical Medical Review

Clinical Medical Review NurseThe Clinical Medical Review Nurse handles day to day review of professional and institutional claims and provider appeals that require medical review to determine if the claim is eligible for benefits and to support claims processing and/or adjudication. The incumbent will handle pre and post claim medical review for Commercial, Federal and Medicare Advantage Plans. This position assists in determining acceptable medical risk to the organization by analyzing medical information of applicants for enrollment in specific policies. This role will also understand the merits of legal or accreditation actions.Essential Functions:Receives, researches, reviews and analyzes professional and institutional claims using critical thinking, nursing clinical judgment and corporate/medical policies for claims processing and/or adjudication.Performs high-level research on topics identified as actual or potential medical policies.Assesses and communicates impact of information on medical policy.Provides pricing of procedure codes which require individual consideration or are listed as "not otherwise classified" in CPT manual.Interprets the descriptive or medical information utilizing the CPT and HCPCS manuals. Keeps up-to-date on coding rules and standards.Participates in medical policy meetings, nurses' forums, and review sessions with Medical and Dental directors, special projects and task forces committees as assigned.Performs medical underwriting and risk assessment by reviewing applications of potential subscribers, as well as any appropriate medical records.Qualifications:To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.Experience: 3 years acute clinical experience, previous case management, discharge planning or utilization review experiencePreferred Qualifications:Bachelor's degree in NursingKnowledge, Skills and Abilities (KSAs):Ability to effectively communicate and provide positive customer service to every internal and external customerStrong interpersonal skills. Ability to work independently, as well as a member of a teamAdvanced current knowledge of clinical practices and related medical policiesStrong organizational skills, ability to prioritize responsibilities with attention to detailExperience in using Microsoft Office (Excel, Word, Power Point, etc.) and web-based technologyMust possess excellent verbal and written communication skillsRemote EMR access is essential as well as ambulatory practice experienceLicenses/Certifications:RN - Registered Nurse - State Licensure And/or Compact State Licensure RN-VA, DC and or MD Upon Hire Req Or: LPN-Licensed Practical Nurse - State Licensure And/or Compact State Licensure LPN-VA, DC and or MD Upon Hire ReqUpon business need, candidate must be willing to travel to provider locations to retrieve medical recordsAdditional Skills: Ambulatory Practice Remote EMR AccessTalteam Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, or protected veteran status and will not be discriminated against on the basis of disability.