Clinical Medical Review Nurse

Job TitleJob Overview: Pay Range: $36.49hr - $41.49hrResponsibilitiesReview, research, and analyze professional and institutional claims using clinical judgment and medical policies for accurate adjudication.Conduct high-level research on medical topics and assess impact on medical policy development.Provide pricing for procedure codes requiring individual consideration or classified as “not otherwise specified” using CPT and HCPCS guidelines.Interpret medical and procedural information in alignment with coding standards and regulatory requirements.Participate in medical policy meetings, nursing forums, and review sessions with medical and dental leadership.Contribute to special projects, task forces, and cross-functional initiatives.Perform medical underwriting and risk assessment by reviewing applications and medical records of potential members.Required QualificationsMinimum 3 years of acute clinical experience.Experience in case management, discharge planning, or utilization review.Strong understanding of clinical practices and medical policy application.Proficiency in Microsoft Office (Excel, Word, PowerPoint) and web-based systems.Experience working with Electronic Medical Records (EMR) systems.Excellent verbal and written communication skills.Preferred QualificationsBachelor’s degree in Nursing.Key SkillsClinical claims review and adjudication.Medical coding knowledge (CPT, HCPCS).Medical policy analysis and research.Risk assessment and underwriting support.Strong analytical and critical thinking abilities.Attention to detail and organizational skills.Ability to work independently and collaboratively.Customer service and stakeholder communication.