Clinical Review & Correspondence RN
Core
Conduct medical necessity reviews and prepare compliant clinical determinations and communications for health plans.
Role type
Utilization Management Registered Nurse
Builds
Clinical determinations and member/provider correspondence
Domain
Healthcare / Utilization Management
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Registered Nurse license, Utilization Management experience, Knowledge of NCQA and CMS standards, Clinical experience (3+ years), Mac proficiency, G Suite proficiency
Preferred skills
Experience developing member/provider correspondence, Understanding of care pathways and utilization algorithms
Responsibilities
Consult with Medical Directors on clinical determinations, Prepare compliant member and provider communications, Document clinical information accurately, Meet productivity and turnaround time expectations
Seniority
Mid-level, hands-on IC