Clinical Medical Review Nurse

Pay Range: $36.49hr - $41.49hr Job Overview: The Clinical Medical Review Nurse handles the 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 candidate 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. Essential Functions: Receives, researches, reviews, and analyzes professional and institutional claims using critical thinking, nursing clinical judgment, and corporate or medical policies for claims processing and adjudication; performs high-level research on topics identified as actual or potential medical policies; and assesses and communicates the impact of information on medical policy. Provides pricing of procedure codes which require individual consideration or are listed as "not otherwise classified" in the CPT manual; interprets descriptive or medical information utilizing CPT and HCPCS manuals; and 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 force 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 of acute clinical experience, with previous case management, discharge planning, or utilization review experience. Preferred Qualifications: Bachelor's degree in Nursing. Knowledge, Skills and Abilities (KSAs): Ability to effectively communicate and provide positive customer service to every internal and external customer. Strong interpersonal skills with the ability to work independently, as well as a member of a team. Current knowledge of clinical practices and related medical policies. Strong organizational skills and ability to prioritize responsibilities with attention to detail. Proficient in using Microsoft Office (Excel, Word, PowerPoint) and web-based technology. Must possess excellent verbal and written communication skills. Remote EMR access is essential, as well as ambulatory practice experience. Licenses/Certifications: RN - Registered Nurse - State Licensure and/or Compact State Licensure (VA, DC, and/or MD) required upon hire, or LPN - Licensed Practical Nurse - State Licensure and/or Compact State Licensure (VA, DC, and/or MD) required upon hire. Upon business need, the candidate must be willing to travel to provider locations to retrieve medical records. Benefits: Our Benefits Include: Medical, Dental, and Vision Insurance 401(k) Retirement Plan Health Savings Account (HSA) Disability Insurance (Short-Term and Long-Term) Life and AD&D Insurance Paid Sick Leave (where required by applicable state or local law) Supplemental Insurance Plans Identity Theft Protection Pet Insurance Employee Wellness Programs Employee Assistance Program (EAP) Career Growth and Professional Development Opportunities Disclaimer: Benefits eligibility, accrual rates, and usage limits may vary based on employment status, length of service, and work location. Paid Sick Leave is provided in strict accordance with applicable state and municipal mandates. Cynet Systems Inc. reserves the right to modify, amend, or terminate any benefit plans at any time in accordance with applicable laws. About Cynet Systems Founded in 2010 and headquartered in the Washington, DC metro area, Cynet Systems Inc. is a leading technology staffing and workforce solutions company serving Fortune 500 companies, government agencies, and enterprise organizations across the United States and Canada. We deliver agile, scalable talent solutions across IT, engineering, life sciences, clinical, and professional staffing, powered by a high-performing recruitment engine operating across North America and Asia. As a nationally and locally certified Minority Business Enterprise (MBE), Cynet Systems is committed to helping organizations build high-performing teams while empowering professionals to grow rewarding careers. Our organization is certified to ISO 9001, ISO 14001, ISO 27001, and SOC 2 Type II standards, reflecting our commitment to quality, security, operational excellence, and customer success.