Title: Registered Nurse (Utilization Management / Care Management)
Duration: 9 Months+
Location: Baltimore, MD (Remote Job)
The resource is required to report to Canton Baltimore, MD periodically
Required Experience:
5 years Clinical nursing experience in hospital setting
3 years Care Management / Utilization Management
Should have good experience with MCG (Milliman care guidelines)
In lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.
Working knowledge of managed care and health delivery systems.
Working knowledge of IT and Medical Management systems, familiarity with web-based software application environment and the ability to confidently use the internet as a resource.
Job Details :
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.
Licenses/Certifications:
RN - Registered Nurse / LPN
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