Registered Nurse (RN) with active license in the state of Tennessee or hold a license in the state of their residence if the state is participating in the Nurse Licensure Compact Law.
Experience
3 years - Clinical experience required
Skills\Certifications
Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)
Working knowledge of URAC, NCQA and CMS accreditations
Must be able to work in an independent and creative manner.
Excellent oral and written communication skills
Strong interpersonal and organizational skills
Ability to manage multiple projects and priorities
Adaptive to high pace and changing environment
Customer service oriented
Superior interpersonal, client relations and problem-solving skills
Proficient in interpreting benefits, contract language specifically symptom-driven, treatment driven, look back periods, rider information and medical policy/medical review criteria
Responsibilities
Job Description Summary: Perform comprehensive clinical review of requested services utilizing clinical criteria, received through various mechanisms.
Job Responsibilities
Initiate referrals to ensure appropriate coordination of care.
Seek the advice of the Medical Director when appropriate, according to policy.
Assists non-clinical staff in performance of administrative reviews
Performing comprehensive provider and member appeals, denial interpretation for letters, retrospective claim review, special review requests, and UM pre-certifications and appeals, utilizing medical appropriateness criteria, clinical judgement, and contractual eligibility.
Weekend work required as needed.
Must be able to pass Windows navigation test.
Testing/Assessments will be required for Digital positions.
Seniority level
Mid-Senior level
Employment type
Full-time
Job function
Health Care Provider
Industries
Staffing and Recruiting
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