Title: Registered Nurse (HEDIS)
Duration: 12 Months+
Location: Baltimore, MD (Remote Job)
Required Experience:
Should be a LPN / RN OR Licensed Nurse is required (Certification is not required but License is) Compact license
Bachelors degree in nursing is preferred
5 years of HEDIS experience is required if no bachelors then 10 years of experience needed
should have EMR experience EPIC, Clinical, Cerner, Medical records
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 - Should have License, certification is not required
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