Nurse 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 quality of care issues, service or treatment delays and intervenes or as clinically appropriate.
• Provides referrals to Case Management, Disease Management, Appeals and Grievance and Quality 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 well independently

Preferred Skills (nice 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 engine, limited excel required