Clinical Medical Review Nurse
System One
Baltimore, MD
Job Title: Clinical Medical Review Nurse
Location: Baltimore, MD
Type: Contract
Compensation: $41.50/HR
Contractor Work Model: Hybrid
Purpose
The Clinical Medical Review Nurse conducts pre? and post?claim medical reviews of professional and institutional claims and provider appeals to determine benefit eligibility and support accurate claims adjudication. This role applies clinical judgment, medical policy, and coding standards to assess medical necessity, appropriateness, and medical risk, while supporting medical policy development and regulatory compliance.
Essential Duties and Responsibilities
- Review, research, and analyze professional and institutional claims requiring medical review, applying clinical expertise, critical thinking, and medical policy to support claims processing and adjudication.
- Conduct pre? and post?payment medical reviews, including complex or escalated claims and provider appeals.
- Evaluate medical documentation and supporting records to determine medical necessity, appropriateness, and benefit eligibility.
- Perform clinical research on identified issues to support medical policy development, interpretation, and updates.
- Provide pricing recommendations for procedure codes requiring individual consideration or classified as unlisted or not otherwise specified, utilizing CPT, HCPCS, and current coding guidelines.
- Participate in medical policy meetings, interdisciplinary forums, review sessions, and assigned special projects.
- Perform medical underwriting and risk assessment by reviewing enrollment applications and medical records to evaluate acceptable medical risk.
- Maintain current knowledge of clinical practices, medical policies, coding standards, and regulatory requirements.
Qualifications
Required Experience (RN and LPN)
- Minimum of three years of acute clinical nursing experience
- Prior experience in utilization review, medical review, case management, or discharge planning
RN (Registered Nurse) Qualifications
Education
- Associate or Bachelor’s degree in Nursing (BSN preferred)
Licensure
- Active RN license in state of practice or compact state
- Multi?state licensure preferred (MD, DC, VA)
LPN (Licensed Practical Nurse) Qualifications
Education
- Graduate of an accredited Practical Nursing program
Licensure
- Active LPN license in state of practice or compact state
- Multi?state licensure preferred (MD, DC, VA)
Additional LPN Preferences
- Ambulatory, utilization review, or non?bedside clinical experience preferred
Knowledge, Skills, and Abilities
- Strong clinical judgment and critical?thinking abilities
- Excellent verbal and written communication skills
- Ability to work independently and collaboratively within a team environment
- Strong organizational skills with the ability to manage competing priorities and meet deadlines
- Proficiency in Microsoft Office applications and web?based systems
- Experience working with electronic medical records (EMR) systems
- Ability to consistently provide professional, solutions?focused customer service in a fast?paced environment
Additional Requirements
- Must disclose any debarment, exclusion, or other conditions that impact eligibility to perform work related to federally funded healthcare programs
- Ability to work effectively in a fast?paced environment with changing priorities, deadlines, and workloads
- Ability to manage multiple internal and external service demands while meeting performance expectations
System One, and its subsidiaries including Joulé and Mountain Ltd., are leaders in delivering outsourced services and workforce solutions across North America. We help clients get work done more efficiently and economically, without compromising quality. System One not only serves as a valued partner for our clients, but we offer eligible employees health and welfare benefits coverage options including medical, dental, vision, spending accounts, life insurance, voluntary plans, as well as participation in a 401(k) plan.
System One is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, age, national origin, disability, family care or medical leave status, genetic information, veteran status, marital status, or any other characteristic protected by applicable federal, state, or local law.
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About the Company
System One
Every day, System One focuses on services and solutions that require a high degree of specialization, in-demand technical skills, and large-scale operational expertise. We are essential partners to those on the front lines of our nation’s most critical infrastructure, technology, and life sciences initiatives.
Founded more than 40 years ago as a staffing partner to the engineering industry, today System One is a diversified organization operating in over 50 locations and putting more than 9,000 people to work in the United States, Canada, and the United Kingdom.