Nursing

• Responsible to collaborate with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources.
• Works with medical directors in interpreting appropriateness of care and accurate claims payment.
• 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.
• Ensures member access 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.
• Collaborates with providers to assess member's needs for early identification of and proactive planning for discharge planning.

• Requires current unrestricted RN license in applicable states.
• Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.

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