Full Time, Employee

We have multiple opportunities for Medical Management Nurses to work within the Medical Claims Review Department to review medical necessity requests.

The nurse will also review and analyze  high claimant reporting packages and external carrier reporting packages. Development of case summaries including projected claim costs over the next 12 months. Participate in meetings with underwriting team as appropriate to support business needs. Provide support for external presentations and present clinical data as needed to support business needs. Review of stop loss claim submission to identify primary diagnosis, determine if claim detail is consistent with diagnosis, determine if additional information or review is necessary for questionable diagnosis or services rendered.

Qualifications/Software Knowledge:

Registered Nurse

5+ years clinical experience

Coding Experience Required

Prior experience in healthcare insurance industry a plus

Proficient in MS word, Excel

Proficient typing skills

Excellent communication skills