13 clinical nurse rn jobs found in Baltimore

CareFirst BlueCross BlueShield Resp & Qualifications PURPOSE : 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 post claim medical review for Commercial and Federal. 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. We are looking for an experienced RN to work remotely from within the greater Baltimore metropolitan area. The incumbent will be expected to come into a CareFirst location periodically for meetings, training and/or other business-related activities. ESSENTIAL FUNCTIONS: Receives, researches, reviews and analyzes professional and...

CareFirst BlueCross BlueShield Resp & Qualifications PURPOSE: We are looking for an experienced Nurse Care Manager to work remotely from within the greater Baltimore, Maryland metropolitan area with both Adult and Pediatric members. The incumbent will be expected to come into a CareFirst location periodically for meetings, training and/or other business-related activities. Under minimal supervision, the Nurse Care Manager researches and analyzes the Adult and Pediatric member's medical and behavioral health needs and healthcare cost drivers. The Nurse Care Manager works closely with the member / members family and the interdisciplinary care team to ensure members have an effective plan of care and positive member experience that leads to optimal health and cost-effective outcomes. ESSENTIAL FUNCTIONS: Identifies members with acute/complex medical and/or behavioral health conditions. Engages onsite and/or telephonically with member, family and providers to...

CareFirst BlueCross BlueShield Resp & Qualifications PURPOSE: 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 claim medical review for Commercial and Federal lines of business. 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. We are looking for an experienced RN to work remotely from within the greater Baltimore metropolitan area. The incumbent will be expected to come into a CareFirst location periodically for meetings, training and/or other business-related activities. ESSENTIAL FUNCTIONS: Receives, researches, reviews and analyzes...

CareFirst BlueCross BlueShield Resp & Qualifications PURPOSE: We are looking for an RN with significant clinical educator experience to work in a hybrid role from within the greater Baltimore/ Washington metropolitan area. The incumbent will be expected to come into a CareFirst location periodically for meetings, trainings, provide training support for Care Management employees and/or other business-related activities. This role provides relevant new hire and supportive ongoing training/professional development which create and maintain a motivated, skilled and effective team through which organizational goals are achieved. In this position, the incumbent will be supporting all market segments of the Care Management Department providing training for Care Management employees related to new technology and documentation with our Guiding Care platform, the Care Management process, and interventions to drive outcomes for our members. Demonstrated experience with...

CareFirst BlueCross BlueShield Resp & Qualifications PURPOSE: a { text-decoration: none; color: #464feb;}tr th, tr td { border: 1px solid #e6e6e6;}tr th { background-color: #f5f5f5;} This role supports the Dual Special Needs Population (DSNP) in Maryland. Under minimal supervision, the Care Manager conducts thorough research and analysis of members medical and behavioral health needs, along with the key drivers influencing healthcare utilization and costs. The Care Manager partners closely with members and the interdisciplinary care team to develop and implement person-centered plans of care that promote a positive member experience, improved health outcomes, and costeffective service delivery. We are seeking a bilingual Care Manager to enhance communication, cultural responsiveness, and engagement with our diverse DSNP member population. This position is remote, with the expectation that the selected candidate resides within the greater Baltimore metropolitan area....

CareFirst BlueCross BlueShield Resp & Qualifications PURPOSE: The Clinical Appeals Nurse completes research, basic analysis, and evaluation of member and provider disputes regarding adverse and adverse coverage decisions. The Clinical Appeals Nurse utilizes clinical skills and knowledge of all applicable State and Federal rules and regulations that govern the appeal process for Commercial and lines of business in order to formulate a professional response to the appeal request. We are looking for an experienced professional to work remotely from within the greater Baltimore metropolitan area. The incumbent will be expected to come into a CareFirst location periodically for meetings, training and/or other business-related activities. ESSENTIAL FUNCTIONS: Investigates, interprets, and analyzes written appeals and reconsideration requests from multiple sources including applicants, subscribers, attorneys, group administrators, internal stake holders and any other...

CareFirst BlueCross BlueShield Resp & Qualifications PURPOSE: The Onsite Clinical Navigator (RN) embedded at a partnering hospital will conduct concurrent review of inpatient level of care, managing the timely and smooth transition from inpatient care to home or other levels of care. Utilizing experience and skills in both care management and utilization management, the Onsite Clinical Navigator will leverage proficiency in established MCG, in addition to administrative/regulatory considerations, to determine medical necessity, appropriate level(s) of care and case management to engage members/enrollees, their families and other support systems in discharge planning. The role will function as a liaison working onsite at the assigned hospital up to 5 days per week and occasional weekend work may also be required, both at management's sole discretion. Such work will be conducted with the hospital care team including case managers, social workers and discharge planners...

CareFirst BlueCross BlueShield Resp & Qualifications PURPOSE: We are looking for an experienced professional to live and work remotely from within the greater Baltimore/Washington metropolitan area. The incumbent will be expected to come into a CareFirst location periodically for meetings, training and/or other business-related activities. Under minimal supervision, the Care Manager researches and analyzes a member's medical and behavioral health needs and healthcare cost drivers. The Care Manager works closely with members and the interdisciplinary care team to ensure members have an effective plan of care and positive member experience that leads to optimal health and cost-effective outcomes. ESSENTIAL FUNCTIONS: Identifies members with acute/complex medical and/or behavioral health conditions. Engages telephonically with member, family, and providers to develop a comprehensive plan of care to address the members needs at various stages along the care continuum....

CareFirst BlueCross BlueShield Resp & Qualifications (Maryland-DC-Northern VA) PURPOSE: Under minimal supervision, the Care Manager researches and analyzes a member's medical and behavioral health needs and healthcare cost drivers. The Care Manager works closely with members and the interdisciplinary care team to ensure members have an effective plan of care and positive member experience that leads to optimal health and cost-effective outcomes. We are looking for an experienced professional to work remotely from within the greater Baltimore/Washington DC metropolitan areas. The incumbent will be expected to come into a CareFirst location periodically for meetings, training and/or other business-related activities. ESSENTIAL FUNCTIONS: Identifies members with acute/complex medical and/or behavioral health conditions. Engages onsite and/or telephonically with member, family and providers to develop a comprehensive plan of care to address the members needs at...

CareFirst BlueCross BlueShield Resp & Qualifications PURPOSE: The Clinical Navigator (RN) conducts concurrent review of inpatient level of care, managing the timely and smooth transition from inpatient care to home or other levels of care. Utilizing experience and skills in both care management and utilization management, the Clinical Navigator will leverage proficiency in established MCG, in addition to administrative/regulatory considerations, to determine medical necessity, appropriate level(s) of care, and case management to engage members/enrollees, their families and other support systems in discharge planning. The role will function as a liaison working telephonically with the hospital care team including case managers, social workers and discharge planners to ensure CareFirst members/enrollees receive the appropriate level of care and partner to address any potential barriers to discharge. The candidate may be required to come to the CareFirst office location...

CareFirst BlueCross BlueShield Resp & Qualifications PURPOSE: The Onsite Clinical Navigator (RN) embedded at a partnering hospital will conduct concurrent review of inpatient level of care, managing the timely and smooth transition from inpatient care to home or other levels of care. Utilizing experience and skills in both care management and utilization management, the Onsite Clinical Navigator will leverage proficiency in established MCG, in addition to administrative/regulatory considerations, to determine medical necessity, appropriate level(s) of care and case management to engage members/enrollees, their families and other support systems in discharge planning. The role will function as a liaison working onsite at the assigned hospital up to 5 days per week and occasional weekend work may also be required, both at management's sole discretion. Such work will be conducted with the hospital care team including case managers, social workers and discharge planners...

CareFirst BlueCross BlueShield Resp & Qualifications PURPOSE: To support the prevention, reduction of and/or recuperation of losses to CareFirst through the clinical review of medical records and claims, resulting in the savings and/or recovery of funds. Responsible for providing clinical knowledge to the SI team to support both prepayment reviews and/or post-payment investigations. ESSENTIAL FUNCTIONS: Review of medical records and claims. Investigate potential fraud and over-utilization by performing complex medical reviews of claims and medical records. The claims may be in a pre or post payment environment. Provide a detailed but concise analysis to communicate findings about the ability to pay or deny a claim or claim lines using clinical and/or coding, billing, or reimbursement knowledge. Maintain appropriate records and supporting documentation regarding findings in accordance with departmental standards. Process all assigned claims or batch case reviews...

CareFirst BlueCross BlueShield Resp & Qualifications PURPOSE: This role manages the appeal process for members and providers who appeal on behalf of members for Commercial lines of business. Ensures quality management of the clinical appeal process to reduce the risk of State and Federal Regulatory fines and sanctions, avoid adverse exposure, reiterate the expectation of a fair and compliant appeal process for our membership, and support NCQA accreditation and the Divisional Goals for Care Management. We are looking for an experienced clinical leader in the greater Baltimore metropolitan area who is willing and able to work in a hybrid model. The incumbent will be expected to work a portion of their week from home and a portion of their week at a CareFirst location based on business needs and work activities/deliverables that week. ESSENTIAL FUNCTIONS: Develops, establishes and implements a compliant appeal process with dynamic goals resulting in the full and...