Elite Technical is seeking a Clinical Medical Review Nurse that will handle 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.

ESSENTIAL FUNCTIONS:
- 35% 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.
- 25% 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.
- 15% Performs medical underwriting and risk assessment by reviewing applications of potential subscribers, as well as any appropriate medical records.

Required Skills

- A RN or LPN nursing license, issued in the one of the following states is required: MD, VA, DC - or Compact NLC licensure
- Bachelor-s degree in Nursing, Associate-s degree in Nursing, or Diploma in Nursing is mandatory.
- 3+ years of clinical experience is required.
- MS Office, Excel, and the ability to navigate an EMR system is mandatory.
- Must have a outstanding client communications skills, both verbally and written. Must be proactive, and a self starter.

Preferred, not required:
- HEDIS knowledge: Abstraction and over read experience.
- Ambulatory experience
- Medicare and Medicaid measures