RN Nurse

Payrate : $56.15 - $60.00 / hr.

Responsibilities :

• Perform clinical claim reviews and first claim level determination approvals for members using FEP evidenced based guidelines, policies and nationally recognized clinal criteria
• Conducts clinical review of claims for medical necessity, coding accuracy, medical policy compliance and contract compliance
• Prepare and present cases to Medical Director (MD) for medical director oversight and medical necessity determination and communicate determinations to providers and / or members in compliance with federal and accreditation requirements
• Develops and reviews member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards
• Triages and prioritizes cases to meet required turn-around times
• 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.
• Other duties as assigned.

Required Skills :

Preferred Skills (nice to have) :

Education Requirements :

Software Skills Required :

Pay Transparency : The typical base pay for this role across the U.S. is : $56.15 - $60.00 / hr. Final offer amounts, within the base pay set forth above, are determined by factors including your relevant skills, education and experience and the benefits package you select. Full-time employees are eligible to select from different benefits packages. Packages may include medical, dental, and vision benefits, 10 paid days off, 401(k) plan participation, commuter benefits and life and disability insurance.

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