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:
- Performs reviews utilizing established criteria to determine the appropriateness of the service request.
- Communicates with the providers to obtain additional information as needed to make a decision and provides communication around that decision to the provider.
- Educates the providers on the preauthorization process as needed.
- 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.