Responsible in collaborating with healthcare providers and members to promote quality member outcomes, to optimize members’ benefits, and to promote effective use of resources
Ensures 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
BS Nursing (BSN) Degree
Active US State License holder
A minimum of three (3) months’ of prior working experience as a Registered Nurse in a clinical setting required : o Three months is equivalent to 480 hours of working experience as an RN o Working experience as a Registered Nurse means holding an active RN license and providing direct patient care o Clinical setting includes inpatient hospital, outpatient hospital or clinic
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.
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