Preservice Review Nurse RN - Remote MUST BE PST or MST
About the position
The position involves performing clinical coverage review services to ensure members receive appropriate health services. The role requires communication with healthcare providers and members to explain benefit coverage determinations and gather clinical information. It offers the flexibility to work remotely and emphasizes the importance of autonomy and responsibility in decision-making that impacts members' health outcomes.
Responsibilities
Perform clinical coverage review services, interpreting state and federal mandates and applicable benefit language.
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Communicate benefit determinations, including coverage guidelines and reimbursement decisions.
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Speak to healthcare providers and members to explain benefit coverage determinations and obtain additional clinical information.
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Act as a resource for less experienced colleagues.
Requirements
Current unrestricted RN license in the state of residency.
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3+ years of RN experience, including experience in an inpatient/acute setting.
Nice-to-haves
Bachelor's Degree.
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Background involving utilization review for an insurance company or experience in case management.
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Familiarity with Milliman Care Guidelines.
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Proven ability to use diverse knowledge and experience to improve healthcare for patients.
Benefits
Comprehensive benefits package.
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Incentive and recognition programs.
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Equity stock purchase.
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401k contribution.
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