Health Services - Nurse, Clinical Medical Review

Nurse, Clinical Medical Review

Ampcus Inc. is a certified global provider of a broad range of Technology and Business consulting services. We are in search of a highly motivated candidate to join our talented team.

Locations: VA, DC, MD

Job Summary:

The 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, FEP, 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.

Key Responsibilities:

• 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. (35%)
• 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. (25%)
• Participates in medical policy meetings, nurses' forums, and review sessions with Medical and Dental directors, special projects, and task forces committees as assigned. (25%)
• Performs medical underwriting and risk assessment by reviewing applications of potential subscribers, as well as any appropriate medical records. (15%)

Required Qualifications:

• 3 years acute clinical experience, previous case management, discharge planning, or utilization review experience.
• Bachelor's degree in Nursing preferred.
• Ability to effectively communicate and provide positive customer service to every internal and external customer. Proficient in strong interpersonal skills and ability to work independently, as well as a member of a team.
• Current knowledge of clinical practices and related medical policies. Proficient in strong organizational skills, ability to prioritize responsibilities with attention to detail.
• Experience in using Microsoft Office (Excel, Word, PowerPoint, etc.) and web-based technology. Must possess excellent verbal and written communication skills.
• Remote EMR access is essential as well as ambulatory practice experience.
• RN - Registered Nurse - State Licensure And/or Compact State Licensure RN-VA, DC, and or MD Upon Hire Required or LPN-Licensed Practical Nurse - State Licensure And/or Compact State Licensure LPN-VA, DC, and or MD Upon Hire Required.
• Upon business need, candidate must be willing to travel to provider locations to retrieve medical records.

Benefits Overview:

• Health & Wellness: Comprehensive pre-tax health, dental, and vision insurance options.
• Life Insurance: Group term life insurance and voluntary life insurance coverage.
• Retirement Savings: 401(k) retirement savings plan to help you plan for your future.

Ampcus 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, age, protected veterans or individuals with disabilities.