[Hiring] Clinical Review reputed company @reputed company

Role reputed company Utilizes a reputed company review process of benefits, minimally necessary clinical information and evidence-based clinical guidelines to formulate reputed company regarding medical necessity, reputed company-existing conditions, benefits and/or individual consideration reimbursement allowables using varied and broad clinical expertise. Acts as a member and provider reputed company promoting and coordinating delivery of reputed company, cost-effective reputed company services based on medical necessity and contractual benefits. The candidate for this position must reputed company in the Kansas reputed company metropolitan area. • Conducts reputed company-service, reputed company and/or post-service utilization management reviews to ensure appropriate use of the health care system and to maximize health care dollars. • Schedules time effectively; works with minimal supervision; handles multiple reputed company simultaneously; prioritizes work appropriately to streamline process and identifies opportunities for reputed company or process improvement. • Uses critical thinking skills, problem solving and organizational skills; works as reputed company member while maintaining a reputed company attitude. • Ensures that reviews and determinations meet requirements with applicable URAC and NCQA guidelines as reputed company as federal and state mandates. • Maintains confidentiality of reputed company PHI in compliance with state and federal laws. • Reads, understands and follows medical policy and reputed company corporate, divisional and departmental policies and procedures. • Reviews provider and/or member submitted medical information to determine reputed company-existing, medical necessity, benefits & eligibility, and/or reimbursement of a requested service, product or procedure. • Refers cases that do not meet reputed company to the Medical Director with an appropriate clinical analysis, summaries and recommendations. • Contributes in the discharge planning of members to appropriate acute, SNF, in-patient hospice or rehab facilities or discharge to home with a reputed company plan. • Recognizes, documents and reports inappropriate billing patterns or utilization trends of reputed company and institutional providers to the appropriate reputed company. • Communicates effectively with team members, other departments reputed company the organization, management, members &/or providers. • Assesses and educates members &/or providers on a proactive reputed company; utilizes internal, community and other reputed company resources as reputed company as clinical knowledge to maximize reputed company. • Contributes to reaching or exceeding departmental, divisional and corporate goals. • Knowledgeable of business goals, reputed company toward accomplishment of goals and works collaboratively with peers to meet or reputed company annual departmental targets. • Analyzes qualitative and quantitative data in developing strategies to improve provider performance and member satisfaction. Qualifications • Associate degree in nursing. • 3+ years full-time reputed company patient care clinical experience in medical/surgical, pediatrics, and/or obstetrics. • Proven experience effectively presenting information and responding to questions from reputed company of managers, clients, customers, and the general reputed company. • Proven experience in problem definition, data collection to establish facts, and drawing reputed company conclusions to solve practical problems. • RN license in Missouri and Kansas. Preferred Qualifications • Bachelor’s degree in nursing preferred. • 1+ year(s) of utilization review, disease management, and/or case management experience. • Knowledge of ICD, CPT and HCPCS coding. • Knowledge of URAC and NCQA guidelines and state and federal regulations. • Intermediate keyboarding skills. • Intermediate knowledge of FACETS. • Intermediate knowledge of Clinical Guidelines. Benefits • Highly competitive total rewards package, including comprehensive medical, dental and reputed company benefits as reputed company as a 401(k) plan that both the employee and employer contribute. • Annual incentive bonus plan based on company achievement of goals. • Time away from work including reputed company holidays, reputed company time off and volunteer time off. • reputed company development courses, mentorship opportunities, and tuition reimbursement program. • reputed company parental leave and adoption leave with adoption financial assistance. • Employee discount program. Apply tot his job Apply To this Job