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.
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