Nursing - RN Level 2

Job Description: Job Summary: This position is responsible for the medical policy determination of claims/cases consistent with Plan Medical Policy to ensure appropriate and efficient utilization of benefits. Additionally, the position is responsible for the research and analysis of medical techniques, procedures and products and for recommendations in the formulation of draft medical policy.



Responsibilities:

Provide timely and accurate responses to inquiries from the claim policy teams in relation to courtesy pre-d requests, claims pending for medical review and appeal inquiries.

Prepares cases for Medical Director Review and or outside consultant review and response where appropriate.

Responsible for processing pends for which the Medical Policy Inquiry Resolution team has authority to do so.

Identifies opportunities for development of or revisions to Client Medical Policy based on case review.

Responsible for identifying areas and pursuing solutions where medical policy is not being applied correctly in claim payment outcome.

Responsible for managing inventory assigned, documenting production in RMRS and follow through on all assigned inquiries.

Responsible for staying abreast of all mandates, policy changes, workflow changes impacting outcomes.

Performs special projects as assigned by management.

Demonstrates knowledge and understanding of the laws regulations and policies that pertain to the organization unit's business and conforms to these laws, regulations and policies in carrying out the accountabilities of the job.





Qualifications:

Education/Experience

1. Requires an associate or bachelor's degree (or higher) in nursing and/or a health-related field OR accredited diploma nursing school.

2. Requires a minimum of two (2) years clinical experience.

3. Requires minimum of three (3) years' experience in the health care delivery system/industry.





Additional licensing, certifications, registrations

Active Unrestricted RN License Required; NJ License Preferred

Prefer Certified Professional Coder credentials.



Knowledge - Must be proficient in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint) and Lotus Notes; Should be knowledgeable in the use of intranet and internet applications.



Skills and Abilities -

Must have effective verbal and written communication skills and demonstrate the ability to work well within a team.

Demonstrated ability to deliver highly technical information to less technical individuals.

Must demonstrate professional and ethical business practices, adherence to company standards, and a commitment to personal and professional development.

Proven time management skills are necessary. Must demonstrate the ability to manage multiple priorities [or tasks], deliver timely and accurate work products with a customer service focus, and respond with a sense of urgency as required.

Demonstrated ability to work in a production focused environment.

Proven ability to exercise sound judgment and strong problem-solving skills.

Proven ability to ask probing questions and obtain thorough and relevant information.

Must be client service focused with effective ability to empathize.