Staff Nurse - RN, Sr. - Medical Management
Also referred to as: Patient Benefit and Care Nurse Coordinator II, Patient Care Authorization Senior Nurse, Senior Nurse Manager, Care Coordination, Senior Nurse Manager, Member Benefit Coordination
Requirements and Responsibilities
Leads the coordination between care providers and plan members with the goal of maximizing member benefits while managing costs. Oversees the assessment of medical necessity of procedures and/or admissions, conducts pre-certification or authorization, and ensures compliance with established guidelines. Assists members in appeals for denied services. Interprets benefits and guides members to choose to the appropriate providers, projects and resources. Applies the medical and reimbursement policies within the claim adjudication process. Typically requires a bachelor's degree in Nursing. Typically reports to a manager. Requires RN license. Typically requires more than 5 years of related experience. Contributes to moderately complex aspects of a project. Work is generally independent and collaborative in nature.
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Level of Education:  Staff Nurse - RN, Sr. - Medical Management Salaries with No Diploma, Staff Nurse - RN, Sr. - Medical Management Salaries with a High School Diploma or Technical Certificate, Staff Nurse - RN, Sr. - Medical Management Salaries with an Associate's Degree, Staff Nurse - RN, Sr. - Medical Management Salaries with a Bachelor's Degree, Staff Nurse - RN, Sr. - Medical Management Salaries with a Master's Degree or MBA, Staff Nurse - RN, Sr. - Medical Management Salaries with a JD, MD, PhD or Equivalent
Categories:  Healthcare -- Nursing, Insurance, Non-Profit and Social Services
Industries:  Business Services, Edu., Gov't. & Nonprofit, Healthcare, Insurance,
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