Remote Medical Policy Review RN

The Judge Group is currently seeking a remote Medical Policy Review RN for a fantastic client of ours! Are you passionate about ensuring appropriate and efficient utilization of medical benefits? Join our team as a Medical Policy Review Specialist, where you'll play a crucial role in the medical policy determination of claims and cases consistent with Plan Medical Policy. You'll also be responsible for researching and analyzing medical techniques, procedures, and products, and making recommendations for draft medical policy. Job Title: Medical Policy Determination Specialist Location: Remote but must reside in NJ, PA, NY, DE, or CT and have an active RN license in the state of NJ

Provide timely and accurate responses to inquiries from the claim policy teams in relation to courtesy pre-d requests, claims pending for medical review, and appeal inquiries. Prepare cases for Medical Director Review and/or outside consultant review and response where appropriate. Process pends for which the Medical Policy Inquiry Resolution team has authority to do so. Identify opportunities for development of or revisions to Horizon Medical Policy based on case review. Identify areas and pursue solutions where medical policy is not being applied correctly in claim payment outcomes. Manage inventory assigned, document production in RMRS, and follow through on all assigned inquiries. Stay abreast of all mandates, policy changes, and workflow changes impacting outcomes. Perform special projects as assigned by management. Demonstrate knowledge and understanding of the laws, regulations, and policies that pertain to the organization unit's business and conform to these laws, regulations, and policies in carrying out the accountabilities of the job.