The responsible person prepares, presents, and refers cases, as needed, to the physician medical directors (MDs) for cases reviewed and not meeting approval criteria. Promotes and coordinates the delivery of quality, cost effective health care services based on medical necessity per the benefit plan. Communicates with providers to increase provider awareness of medical criteria and policy as it relates to services requested. Works with providers to assure effective and efficient care management. Meets with providers, as needed. Maintains confidentiality of all PHI in compliance with state and federal laws. May initiate face to face member visits to provide education on available benefits for medical needs.
What your background should be
RN or LPN with valid NC license required. 3 years previous clinical nursing experience, preferably in a variety of clinical settings, or 2 years in a health insurance related industry such as utilization management processes, managing health conditions, understanding medical criteria, medical guidelines, medical policy, and NCQA and DOI regulations. Additional Critical Skills & Knowledge Needed for Job, BSN strongly preferred. Excellent oral and written communication skills.
Required Schooling / Training
Not specified
Who is the client company
The company provides health insurance to over 100 million Americans.
If you are interested in this position, send your resume to apply@kochdavis.com
