Job Description

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BSc MSc nursing with NCLEX certification and active US RN license NCLEX Certified Nurse with 5 years of clinical experience

Key Responsibilities:

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Senior SME Skillset Training Data Management and reporting Quality Tools Descriptive Analysis New project Implementation Perform medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and Standard Operating procedures Clinical knowledge and ability to analyze authorization requests and determine medical necessity of service preferred Good understanding of US healthcare business Knowledge of utilization management processes preferred Ability to understand Milliman guidelines preferred Knowledge of managed care acute care emergency room cardiology radiology etc Understanding of ICD and CPT codes

Technical Requirements:

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Primary skills Operations Clinical Data Management Microsoft Word Excel Computer navigation typing skills effective communication skills both verbal and written

Preferred Skills:

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Operations->Clinical Data Management