Medical Review Nurse

This is a fully remote position, open to applicants in Minnesota, +1 more state.

📋 Description

• Support underwriters in assessing clinical and claims data during the disclosure phase to pinpoint potential risks.

• Collaborate with Third-Party Administrators and producers as a medical expert for the management of catastrophic claims.

• Aid Case Managers with high-value catastrophic claimants.

• Analyze claims reporting to identify potential exposure and make reserve recommendations.

• Perform clinical reviews and claims analysis to evaluate claim trends and potential group resources.

• Ensure patient confidentiality in accordance with IOA and HIPAA regulations.

• Assist in identifying and engaging new business partners to enhance healthcare resources and reduce claims exposure.

• Act as a backup for other medical staff within the department as required.

• Keep licensure and certifications current for professional growth.

⛳️ Requirements

• Preferred Registered Nurse licensure.

• Bachelor’s degree in nursing or a related science field.

• CCM certification is preferred.

• Minimum of one year of acute care clinical experience is mandatory.

• Experience in Utilization Management (UM) or Case Management (CM) on either the payer or provider side.

• Previous experience with TPA, MGU, or Stop Loss carrier is highly preferred.

• Familiarity with analyzing healthcare claims and coding.

• Prior experience in dealing with catastrophic healthcare claims.

• Competence in data entry and the analysis of medical reports.

• Ability to perform risk assessments and convey analyses clearly in reports.

• Capacity to conduct independent medical research as a complement to medical underwriting duties.

• Skill in adhering to tight deadlines.

• Strong organizational and time management abilities.

• Capability to work autonomously in a remote environment.

• Aptitude for collaborating with multiple offices and underwriters while prioritizing timelines.

• Excellent data entry proficiency.

• Proficient in MS Office applications.

• Ability to communicate effectively and professionally with internal teams and external clients.

• Maintain necessary licensure and certifications.

🏝️ Benefits

• Competitive salary and a comprehensive benefits package.

• Year-round social and community engagement events.

• Continuous mentorship and opportunities for professional development.

• Abundant prospects for career advancement.

• A collaborative and results-oriented work environment.