**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 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 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. The ideal candidate will have previous experience making clinical decisions related to post claim submis...