Nurse Medical Mgt I or II
Location: South Portland Maine
Description: WellPoint, Inc is at present looking to employ Nurse Medical Mgt I or II right now, this job will be placed in Maine. More complete informations about this job opportunity kindly see the descriptions. Location: CT, ME, or NH
Level will be determined based on skills and experience of selected candidate.
Responsible to collaborate with healthcare providers and member! s to promote quality member outcomes, to optimize member 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 steering members to appropriate providers, programs or community resources. Works with medical directors in interpreting appropriateness of care and accurate claims payment. May also manage appeals for services denied. Essential duties may include, but are not limited to:
- Conducts pre-certification, concurrent, retrospective, out of network and appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member el! igibility, benefits, and contracts.
- Ensures member ac! cess to medical necessary, quality healthcare in a cost effective setting according to contract.
- Consult with clinical reviewers and/or medical directors to ensure medically appropriate, high quality, cost effective care throughout the medical management process.
- Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.
- Performs other duties as assigned.
Requires current unrestricted RN license in CT.
2 years acute care clinical experience.
Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
Keyboarding and general PC skills preferred.
Previous experience in a Managed Care setting preferred.
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If you were eligible to this job, please email us your resume, with salary requirement! s and a resume to WellPoint, Inc.
If you interested on this job just click on the Apply button, you will be redirected to the official website
This job starts available on: Sat, 19 Oct 2013 11:33:25 GMT