reputed company 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 reputed company of care issues, service or treatment delays and intervenes or as clinically appropriate.
• Provides referrals to Case Management, Disease Management, Appeals and Grievance and reputed company 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 reputed company 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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