Senior Registered Nurse

Responsibilities:
• Performs comprehensive pre-existing reviews and makes clinical determinations of pre-existing or not pre-existing status based on medical judgment and contractual eligibility of the services provided. The comprehensive review includes review of related claims and customer service documentation, and review and interpretation of all medical records. Performs these reviews in a timely manner meeting departmental and corporate turnaround requirements. • Performs thorough research and provides complete documentation for rationale to support both determinations of pre-existing and not pre-existing, as well as specific written instructions regarding additional information necessary to complete the review.
• In addition to initial pre-existing reviews, performs review of rider-related diagnoses, potential misrepresentation referrals, provider and member appeals, and rider-related drug appeals.
• Seeks the advice of the Utilization Management Medical Director as appropriate.
• Proficient in interpreting benefits, contract language specifically symptom-driven, treatment-driven, look-back periods, and rider information, and medical policy language.
• Knowledgeable of all types of pre-existing reviews and have the flexibility to perform each type of review (group, PHC and TRH).
• Utilizes the following system applications when performing reviews: FACETS, FileNet, Outlook, and Intranet, Internet Explorer to research and cross-reference diagnoses and treatment, Microsoft Office, Encoder Pro, Adobe Reader, Adobe Writer, and TRH Imaging software to review applications for potential misrepresentation referrals.
• Navigates in FileNet using all methods for locating and retrieving medical records associated with the specific claim to be reviewed as well as related claims.
• Maintains and/or assists with tracking reporting, and audits to monitor productivity, turnaround times, and quality. • Interacts with Claims, Customer Service, Compliance, Configuration, and other departments as necessary to ensure all guidelines are followed.
• Performs or participates in special studies or projects as directed by department management.
• Promotes positive public relations with providers, member, employees, and the community at large.
• Assists or performs other duties as assigned.