Job Description

• To provide support to the clinical team and client team to assist in the promotion of quality member outcomes, to optimize member benefits, and to promote effective use of resources. Supports the procedures that ensure adherence to medical policy and member benefits in providing service that is medically appropriate, high quality, and cost effective.
• Determine customer eligibility by reviewing contractual language and medical documentation, interpret information and make decisions based on facts presented.
• Assess medical appropriateness of claims submitted, and adjust claims as needed.
• Pay all covered claims accurately and timely.
• Manage both new claims and open claims equally and maintains decision turnaround times.
• Understand the client’s operations and corporate compliance, policies and procedures and best practices.

• BS Nursing (BSN) Degree
• Active PHRN 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, outpatient hospital or clinic
• 1 year of customer service or call-center experience and minimum of work experience is a plus
• Should be flexible