- Job description
* Responsible in collaborating with healthcare providers and members to promote quality member outcomes, to optimize members’ benefits, and to promote effective use of resources<br/>
* Ensure 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. <br/>
* Work with medical directors in interpreting appropriateness of care.
+ Basic qualifications
*Bachelor of Science in Nursing (BSN) degree/General Nursing & Midwifery Diploma/BSN degree/Associate Nursing Degree/Nursing Diploma
*Holds current and unrestricted USRN license and state-specific RN licensure as required.
* Proficient analysis and problem-solving capabilities
* Excellent written and verbal communication skills in English, required
* Basic computer knowledge with the ability to learn additional computer programs, required
* One year of customer service or call center experience, preferred
* Claim reviews/audit experience, preferred