Utilizes effective communication, courtesy and professionalism in all interactions, both internally and externally. Assists and supports customer/account management processes as required.
Evaluates medical information against Milliman criteria, benefit plan, and coverage policies and determines necessity for procedure and refers to Medical Director if criteria is not met
- Adheres to quality assurance standards and all utilization management policies and procedures.
- Attains established production and quality standards and operational objectives -
- Participate on special projects as assigned
Reviews outpatient and inpatient failure to secure authorization claims
Review provider appeals once trained.
Follow all claim nurse review policies and procedures. Requirements
Current RN licensure (unrestricted)
- Maintain active nursing as required by state and company guidelines.
- Recent clinical or Utilization Review experience
- BSN preferred
- Computer skills and typing expertise
- Clinical experience in acute setting for 3 or more years
- Utilization Management experience
- Excellent time management, organizational, research, analytical, customer service, communication (verbal and written) and interpersonal skills.
- Ability to work in an automated environment
- Ability to function as part of a team
- Ability to multi-task
- Knowledge of Utilization Management and Insurance Industry desired.
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