Conduct UM pre-service, concurrent, retrospective, out of network, and appropriateness of treatment setting.

Reviews service requests to ensure compliance with applicable criteria, medical policy, and member eligibility benefits, and contracts.

Utilize client specific criteria sets (e.g., Milliman or InterQual), applicable client specific medical policy and client clinical guidelines for decision making to either approve or summarize and route to Client's nursing reviewer and/or Client's medical staff for review.

Accurately routes cases to client medical staff for further review when a service or admission does not meet medical necessity, place of service, or benefit criteria.

Responsible for conducting medical management review activities which require the review of clinical information against client specific criteria as noted above but excludes denial determinations.

Ensure member access to medically necessary, quality healthcare in a cost-effective setting according to contract. Consult with clinical reviewers and/or U.S.-licensed medical directors to ensure medically appropriate, high-quality, cost-effective care throughout the medical management process.

Collaborate with providers to assess members, needs for early identification of and proactive planning for discharge planning. Facilitate member care transition through the healthcare continuum and refer treatment plans/plan of care to clinical reviewers as required.

Determine contract and benefit eligibility; obtain/confirm intake (demographic) information from callers and/or faxes.

Holds current and unrestricted US Registered Nurse license.

Holds state specific RN licensure as required.

Bachelor of Science Nursing (BSN) degree.

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, outpatient hospital or community clinic (excludes hotel nurse,

school, airport, transport, or company nurse. Requires copy of JD from employer and requires internal

CVE (clearance via exception).

Excellent written and verbal communication skills in English.

Health Clinical Services Senior Analyst