Responsible in collaborating with healthcare providers and members to promote quality member outcomes, to optimize members’ benefits, and to promote effective use of resources
Ensure medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting by utilizing the applicable medical policy and industry standards, accurately interpreting benefits and managed care products, and may steer members to appropriate providers, programs or community resources.
Work with medical directors in interpreting appropriateness of care.
Bachelor of Science in Nursing (BSN) degree / General Nursing & Midwifery Diploma / BSN degree / Associate Nursing Degree / Nursing Diploma *Holds current and unrestricted USRN license and state-specific RN licensure as required.
Proficient analysis and problem-solving capabilities
Excellent written and verbal communication skills in English, required
Basic computer knowledge with the ability to learn additional computer programs, required
One year of customer service or call center experience, preferred
Claim reviews / audit experience, preferred
Equal Employment Opportunity Statement
All employment decisions shall be made without regard to age, race, creed, color, religion, sex, national origin, ancestry, disability status, veteran status, sexual orientation, gender identity or expression, genetic information, marital status, citizenship status or any other basis as protected by federal, state, or local law.
Job candidates will not be obligated to disclose sealed or expunged records of conviction or arrest as part of the hiring process.
Accenture is committed to providing veteran employment opportunities to our service men and women.