Registered Nurse

Registered Nurse

This position is responsible for the medical policy determination of claims/cases consistent with Plan Medical Policy to ensure appropriate and efficient utilization of benefits. Performs duties as assigned by management. Responsibilities include providing timely and accurate responses to inquiries from the claim policy teams in relation to courtesy pre-determination requests, claims pending for medical review and appeal inquiries. Prepares cases for Medical Director Review and or outside consultant review and response where appropriate. Responsible for processing pends for which the Medical Policy Inquiry Resolution team has authority to do so. Identifies opportunities for development of or revisions to Client Medical Policy based on case review. Responsible for identifying areas and pursuing solutions where medical policy is not being applied correctly in claim payment outcome. Responsible for managing inventory assigned, documenting production and follow through on all assigned inquiries. Responsible for staying abreast of all mandates, policy changes, workflow changes impacting outcomes. Performs special projects as assigned by management. Demonstrates knowledge and understanding of the laws regulations and policies that pertain to the organization unit's business and conforms to these laws, regulations and policies in carrying out the accountabilities of the job. Completes other assigned functions as requested by management.

Requires an associate's or bachelor's degree (or higher) in nursing and/or a health related field OR accredited diploma nursing school. Requires a minimum of two (2) years clinical experience.