RN Level 2

US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions. To know more about US Tech Solutions, please visit www.ustechsolutions.com.

This position is responsible for the medical policy determination of claims/cases consistent with Plan Medical Policy to ensure appropriate and efficient utilization of benefits. Additionally, the position is responsible for the research and analysis of medical techniques, procedures and products and for recommendations in the formulation of draft medical policy.

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. Prepares cases for Medical Director Review and or outside consultant review and response where appropriate. Responsible for processing pends for which the Medical Policy Inquiry Resolution team has authority to do so. Identifies opportunities for development of or revisions to Horizon Medical Policy based on case review. Responsible for identifying areas and pursuing solutions where medical policy is not being applied correctly in claim payment outcome. Responsible for managing inventory assigned, documenting production in RMRS and follow through on all assigned inquiries. Responsible for staying abreast of all mandates, policy changes, workflow changes impacting outcomes. Performs special projects as assigned by management. Demonstrates knowledge and understanding of the laws regulations and policies that pertain to the organization unit's business and conforms to these laws, regulations and policies in carrying out the accountabilities of the job.