- Job description
- Responsible to collaborate with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources.
- Ensures medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting by utilizing the applicable medical policy and industry standards, accurately interpreting benefits and managed care products, and may steer members to appropriate providers, programs or community resources.
- Works with medical directors in interpreting appropriateness of care.
+ Basic qualifications
1) Bachelor of Science Nursing (BSN) degree or General Nursing & Midwifery (GNM) Diploma or Bachelor of Science (BS) in Nursing degree or Associate Nursing Degree or Nursing Diploma
2) Holds current and unrestricted US Registered Nurse license. Holds state specific RN licensure as required.
3) Proficient analysis and problem solving capabilities
4) A minimum of 3 months of prior working experience in a clinical setting required
5) Excellent written and verbal communication skills in English, required
6) Basic computer knowledge with the ability to learn additional computer programs, required
7) Claim reviews/audit experience, preferred
9) A minimum of 2 years clinical nursing experience is plus but not required