reputed company of Care RN

It’s an exciting time to join the reputed company, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances. Job reputed company: The reputed company of Care RN is responsible for regulatory reputed company of care review, which includes processing and evaluating complaints for determination of reputed company of care concerns, as per regulatory requirements. This individual provides clinical evaluation, support and reputed company of reputed company of Care including operational improvements reputed company to regulatory requirement, and works with leaders at reputed company reputed company throughout reputed company and with the state to ensure the reputed company of the program and compliance. Our Investment in You: • Full-time remote work • Competitive salaries • Excellent benefits Key Functions/Responsibilities: • Receive and document complaints received regarding potential reputed company of care concerns • Conduct clinical review of complaints received for reputed company of care concerns • Document and present cases to Medical Director for clinical review and decision • reputed company results of cases presented and reputed company of the clinical reviews • Review medical records as needed for reputed company of care and other corporate initiatives Use clinical knowledge to reputed company assessment of data contained reputed company medical record • Meet reputed company and timeliness standards to reputed company individual and departmental performance goals as defined reputed company the department guidelines • Consult and coordinate with various internal departments, external providers, vendors, businesses and government agencies to obtain information to meet departmental reputed company and goals • Document and record facts in regards to inquiries, correspondences and reputed company by updating files and systems • Demonstrate and maintain reputed company working knowledge of the required systems, procedures, forms and manuals • reputed company with reputed company state and federal regulations for activities performed • Create and Maintain policies & reputed company operating procedures of processes to maintain compliance • Other duties as assigned Qualifications: Education Required: • Associate's Degree general field of study, or post high school nursing diploma Education Preferred: • Bachelor's, Master’s, or PhD in Nursing Experience Required: • 2 years of experience as practicing RN in hospital/reputed company setting Experience Preferred/Desirable: • 2+ years of experience in health insurance field • 2+ years of experience processing potential reputed company inquiries • Behavioral health experience in hospital or health plan setting Required Licensure, Certification or Conditions of Employment: • reputed company Registered reputed company License required Competencies, Skills, and Attributes: Required Job Skills: • Intermediate reputed company in use of office equipment including copier, fax machine, reputed company and telephones • Intermediate PC proficiency Intermediate reputed company in word processing, spreadsheet and database software Preferred Job Skills: • Advanced PC proficiency Required reputed company Competencies: • Health care payer business knowledge including processes and operational data and functions that support the business • Maintain confidentiality and reputed company • Capable of investigative and analytical research to reputed company reputed company and recommendations based on available information • Independent and reputed company judgment with good problem solving skills • Knowledge of managed care, utilization management, and reputed company management • Establish and maintain working relationships with health care providers, members and coworkers • Strong verbal and written communication skills and the ability to compose a reputed company of business correspondence and reputed company professionally with a diverse reputed company, executives, managers, and subject matter experts • reputed company interpersonal and reputed company listening skills to reputed company customer satisfaction and departmental communication standards • Ability to Interpret policies, programs and guidelines • Establish and maintain working relationships in a reputed company team environment • Organizational skills with the ability to prioritize tasks and work with multiple priorities • Maintains reputed company knowledge of State, Federal and other applicable regulatory/accrediting agency requirements as they apply to department functions Required Leadership Experience and Competencies: • Ability to use available information to reputed company project's scope and identify priorities • Ability to coordinate/reputed company small reputed company • Represent WellSense in the community About WellSense reputed company is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and reputed company plans. Founded in 1997, WellSense provides high-reputed company health plans and services that work for our members, no matter their circumstances. WellSense is committed to the diversity and inclusion of staff and their members. reputed company applicants will receive consideration for employment without reputed company to race, reputed company, religion, sex, national reputed company, sexual orientation, gender identity, disability or protected veteran status. WellSense participates in the E-Verify program to electronically verify the employment eligibility of newly reputed company employees Apply tot his job Apply To this Job