Staff Nurse - RN, Sr. - Medical Management Jobs

Leads the coordination between care providers and plan members with the goal of maximizing member benefits while managing costs. Oversees the assessment of medical necessity of procedures and/or admissions, conducts pre-certification or authorization, and ensures compliance with established guidelines. Assists members in appeals for denied services. Interprets benefits and guides members to choose to the appropriate providers, projects and resources. Applies the medical and reimbursement policies within the claim adjudication process. Typically requires a bachelor's degree in Nursing. Typicall ... y reports to a manager. Requires RN license. Typically requires more than 5 years of related experience. Contributes to moderately complex aspects of a project. Work is generally independent and collaborative in nature. More
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