Health Services - Medical Review 3

Our Client, a Health Insurance company, is looking for a Health Services - Medical Review 3 for their Remote location.
 
Responsibilities:

• Perform retrospective utilization reviews and first level determination approvals for members using client evidenced based guidelines, policies and nationally recognized clinal criteria across lines of business or for a specific line of business such as Medicare and FEP
• 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 necessity determination and communicate determinations to providers and/or members to in compliance with state, federal and accreditation requirements
• Develop and review member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards and identify potential quality of care issues, service or treatment delays and intervenes or as clinically appropriate
• Clearly communicates, is collaborative, while working effectively and efficiently
• Review itemizations for coding logic using industry standards as well as CMS guidelines
• Triages and prioritizes cases to meet required turn-around times
• Identifies potential quality of care issues, service or treatment delays as clinically appropriate.
• Clinical judgment and detailed knowledge of benefit plans used to complete review decisions

• Requires a current California RN License
• Requires at least 5 years of prior relevant experience
• Requires independent motivation, strong work ethic and strong computer navigations skills
• Previous managed care experience including inpatient claims or concurrent review preferred
• Top 3 Required Skills:
• Previous UM/Managed Care Experience, Concurrent or post service inpatient review experience, CA RN Licensure
• Required Certifications: CA RN Licensure

• Health Benefits
• Referral Program
• Excellent growth and advancement opportunities