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Job Title: Clinical Medical Review Nurse

Type: Contract, 5 mos with chance of extension

Compensation: Based on experience starting at $41.50 / hr

Contractor Work Model: Hybrid - Onsite in Baltimore, MD 2–3 days per week, plus occassional travel to providers for record retrieval, as needed.

Clinical Medical Review Nurse / Medical Records Abstraction Specialist

Schedule: 8-hour shifts (start time 8:00 or 8:30 AM); onsite training twice a year (January and June/July)

Residency Requirement: Must live in MD, DC, VA, WV, PA, DE, or NJ

Purpose

This role combines clinical medical review and medical record abstraction responsibilities. The position handles day-to-day review of professional and institutional claims, provider appeals, and medical record abstraction to determine benefit eligibility and support claims processing/adjudication. It includes pre- and post-claim medical review for Commercial, FEP, and Medicare Advantage Plans, as well as HEDIS-related activities. The role also involves medical underwriting and risk assessment, ensuring compliance with corporate and medical policies.

Essential Functions

+ Claims Review & Analysis (35%)

Review and analyze professional and institutional claims using critical thinking, nursing judgment, and corporate/medical policies. Perform high-level research on medical policy topics and assess impact on policy.

+ Pricing & Coding (25%)

Provide pricing for procedure codes requiring individual consideration or listed as “not otherwise classified.” Interpret medical information using CPT and HCPCS manuals; maintain current knowledge of coding rules and standards.

+ Policy & Collaboration (25%)

Participate in medical policy meetings, nurses’ forums, and review sessions with Medical/Dental Directors. Engage in special projects and task force committees as assigned.

+ Medical Underwriting & Risk Assessment (15%)

Review applications and medical records for potential subscribers to determine acceptable medical risk.

+ Medical Record Abstraction & Overreads

Abstract medical records and perform overreads for quality measures (including HEDIS). Navigate EMR systems to retrieve and review records.

Qualifications

+ Licensure: RN (required) or LPN; State or Compact Licensure (MD, VA, DC required upon hire)

+ Experience:

+ Minimum 5 years clinical experience (acute care preferred)

+ Previous case management, discharge planning, or utilization review experience

+ EMR navigation experience

+ Basic Excel and Microsoft Office proficiency

+ Experience in an office setting

+ Ambulatory experience

+ Preferred:

+ Bachelor’s degree in Nursing

+ HEDIS experience (preferred, not required)

Knowledge, Skills, and Abilities

+ Strong interpersonal and communication skills (verbal and written)

+ Ability to work independently and collaboratively

+ Current knowledge of clinical practices and medical policies

+ Strong organizational skills and attention to detail

+ Proficiency in Microsoft Office and web-based technology

System One, and its subsidiaries including Joulé, ALTA IT Services, 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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Ref: #851-Rockville-S1

System One, and its subsidiaries including Joulé, ALTA IT Services, CM Access, TPGS, and MOUNTAIN, LTD., are leaders in delivering workforce solutions and integrated services 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 full-time 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.