Seeking a Medical Review Nurse for a 3-6 month contract position with our customer, a major Healthcare Insurance organization in the Maryland area. The 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. Specifically, we are seeking candidates that are RN or LPN certified, and have specific knowledge with HEDIS medical chart review experience.

This position is a hybrid opportunity, reporting to our clients office in Owings Mills or Canton MD, and possible providers offices in the Maryland area, 1-2x per month.

Required Skills

- RN or LPN certified is a requirement. Willing to accept CMA as a secondary option
- Experience: 3 years clinical experience, previous case management, discharge planning or utilization review experience. Current knowledge of clinical practices and related medical policies.
- Bachelor's or Associate-s degree in Nursing is highly preferred
- Must have 2+ years of recent HEDIS medical chart review experience. CareSeed knowledge considered a BIG PLUS
- Ability to effectively communicate and provide positive customer service to every internal and external customer
- Must have solid MS Excel knowledge