Integrated Resources, Inc

Company Details


Job ID

: 22320


: Chattanooga, TN, USA


: $30.00 per hour

Job Views

: 142


: 07-26-2019

Job Description


• 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.

• 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.

Job Category
Employment Types
Contract - W2
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