Job Summary
A healthcare company is seeking a Remote Clinical Quality Care RN.
Core Responsibilities Include:
- Evaluating pre-certification case review and medical claims case review
- Verifying that service providers were in network, or that a gap in network coverage was present
- Following relevant regulatory guidelines, policies and procedures
Applicants must meet the following qualifications:
- Unrestricted Registered Nursing License
- 2+ years of experience in medical necessity or utilization management/review
- Minimum of 2 years claims review post service
- Minimum of 3 years prior authorization experience
- Experience in auditing or training of clinical and non-clinical teams
- Excellent written and verbal communication skills
