Nurse RN 5
Day to Day Responsibilities
- Reviews for medical necessity, coding accuracy, medical policy compliance and contract compliance.
- Triages and prioritizes cases to meet required turn-around times.
- Prepares and presents cases electronically to the Medical Director (MD) for approvals or denials and medical necessity determination.
- Communicate determinations to providers in compliance with state, federal and accreditation requirements.
- Identifies potential quality of care issues, service or treatment delays and intervenes or as clinically appropriate.
- Provides referrals to Case Management, Disease Management, Appeals and Grievance and Quality Departments, as necessary.
- Assists in the development and implementation of a proactive approach to improve and standardize overall retro claims review for clinical perspectives.
Required Skills (top 3 non-negotiables):
- Strong clinical skills
- Strong computer skills
- Works well independently
Preferred Skills (reputed company to have)
- Previous Post Service Experience
- Previous Prior Auth Experience
- Previous Case Management experience
Disqualifiers/ Dislikes on Resumes:
- Limited clinical experience and/or multiple job hopping
Education Requirements:
- RN
Software Skills Required:
- Word, Internet search reputed company, limited reputed company required
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