Registered Nurse (RN) needed to join the Medical Review team. This role involves conducting pre- and post-payment medical reviews to ensure compliance with established clinical criteria and guidelines. The ideal candidate will use their clinical expertise to assess medical necessity, appropriateness, and reimbursement eligibility while documenting decisions in accordance with regulatory and organizational requirements.
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This role focuses on supporting and maintaining daily operations, particularly in outpatient utilization review, working with medical management on complex cases. It involves ensuring benefit coverage, reviewing eligibility against established criteria, and accurately documenting decisions. Effective communication with physician offices and providers is essential.