Full Time, Employee

We have multiple openings for both full-time and part-time Nurses looking for individuals who will be responsible for the following:

·         Determines medical necessity and appropriateness of the service requested or incurred by reviewing the member’s Clinical information, utilizing established criteria to determine appropriate course of action.

·         Determines when collaboration with the Medical Director/Associate Medical Director is necessary to determine appropriate course of action.

·         Determines when it is necessary to communicate with the provider staff any determinations related to the requested service.

·         Communicates any concerns to the Senior Team Lead for follow up and resolution.

·         Identifies and refers Members with complex needs to the appropriate Clinical Management programs.

·         Identifies and refers Members with Potential Quality of Care issues to Quality Management through the PQI Referral Form and any Quality of Service issues to Customer Service for follow up.

·         Complies with both internal policies and external regulatory requirements regarding member confidentiality.

·         Complies with documentation standards.

·         Complies with CMS, NCQA, ERISA and PA. Act 68, and other state and federal regulations and timeliness standards.

·         Attends and participates in company and departmental meetings and training sessions as required.

·         Practices within the scope of his or her license and/or certification.

To learn more about this opportunity, please submit a resume and an SGC representative will be in touch soon.