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.
Hybrid (occasionally report to OM and Canton offices)
Onsite 1 day per week. (This will change as needed)
Required Skills:
3+ years of Heidis experience is required.
LPN or RN is required
Day to day responsibilities include review medical records and perform EMR searches.