• Performs comprehensive pre-existing reviews, reviews of rider-related diagnoses, potential misrepresentation referrals, rider related drug appeals, provider and member appeals, denial interpretation for letters, retrospective claim review, special review requests, and UM pre-certifications and appeals, utilizing medical appropriateness criteria, nursing judgement, and contractual eligibility . • Performs thorough research and provides complete documentation for rationale to support determinations as well as specific written instructions regarding additional information necessary to complete the review. • Performs or participates in special studies or projects/pilots as directed by departmental management. • Cross functional and accomplished in all ancillary review functions. • May mentor/trains new incumbents and serve as a preceptor. • Seek the advice of the Medical Director when medical judgment is required. • Initiate referrals to accomplish discharge planning when such plans are evident at the time of the request e.g., telephone request for scheduled for total hip replacement. • Assist non-clinical staff in performance of administrative reviews. • Interact with Onsite and Case Management areas to ensure smooth transfer of member information across the continuum of care. • Apply established vendor protocols for authorization processes • Serves as a presentation guide for walk-through surveyors, auditors, group representatives, etc.
Quals-- Education • Registered Nurse in the state of Tennessee or hold a license in the state of their residence if the state is participating in the Nurse Licensure Compact Law required. • Bachelor’s degree in nursing preferred. Experience • Minimum 3 years varied clinical experience required • Proficient knowledge and ability to apply various accreditation requirements (URAC, NCQA, etc.) preferred. • Proficient in interpreting benefits, contract language specifically symptom-driven, treatment driven, look back periods, rider information and medical policy/medical review criteria preferred. Skills/Certifications • Ability to maintain professional and courteous internal communication with various departments, particularly Claims, in the exchange of information. • Must be PC literate with extensive knowledge of Windows and Microsoft Office. Must be able to pass Windows navigation test. • Must possess excellent verbal and written communication skills with problem-solving abilities as well as organizational and interpersonal skills. • Must be able to work independently and handle multiple tasks. • Customer service oriented • Must be adaptive to high pace and changing environment • Occasional weekend work may be required.