· Summary Description
Utilizes clinical expertise for the review of medical records against appropriate criteria in conjunction with contract requirements, critical thinking and decision making skills to determine medical appropriateness, while maintaining production goals and QA standards. Ensures day-to-day processes are conducted in accordance with NCQA, URAC and other regulatory standards.
Active unrestricted RN clinical license, eligible for Ohio reciprocity licensing. Graduation from an accredited Diploma, Associates Degree or Bachelor’s Degree Program
Knowledge of InterQual criteria strongly preferred.
Knowledge of the organization of medical records, medical terminology, and disease process required.
Strong clinical assessment and critical thinking skills required.
Excellent verbal and written communication skills required.
Must be proficient in Microsoft Office and internet/web navigation
Minimum two years of clinical experience in an acute or med-surgical environment required.
Minimum of one year UR and/or Prior Authorization or related experience.