Care Management US RN Data Sr Analyst
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Summary
Care management analyst reviewing medical necessity of inpatient/outpatient services, interpreting managed care benefits, and collaborating with providers and members to ensure cost-effective, appropriate care using medical policy standards.
Overall Purpose:
Responsible to collaborate with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources.
Responsible to collaborate with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources.
Job Description:
- Responsible in collaborating with healthcare providers and members to promote quality member outcomes, to optimize members’ benefits, and to promote effective use of resources
- Ensures medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting by utilizing the applicable medical policy and industry standards, accurately interpreting benefits and managed care products, and may steer members to appropriate providers, programs or community resources
- Work with medical directors in interpreting appropriateness of care
TO QUALIFY:
- BS Nursing (BSN) Degree
- Active US State License holder
- A minimum of three (3) months’ of prior working experience as a Registered Nurse in a clinical setting required:
- Three months is equivalent to 480 hours of working experience as an RN
- Working experience as a Registered Nurse means holding an active RN license and providing direct patient care
- Clinical setting includes inpatient hospital or clinic