* RN with Coding experience would be ideal. 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. Performs duties as assigned by management. Responsibilities: 1. Provide timely and accurate responses to inquiries from the claim policy teams in relation to courtesy pre-determination requests, claims pending for medical review and appeal inquiries. 2. Prepares cases for Medical Director Review and or outside consultant review and response where appropriate. 3. Responsible for processing pends for which the Medical Policy Inquiry Resolution team has authority to do so. 4. Identifies opportunities for development of or revisions to Client Medical Policy based on case review. 5. Responsible for identifying areas and pursuing solutions where medical policy is not being applied correctly in claim payment outcome. 6. Responsible for managing inventory assigned, documenting production and follow through on all assigned inquiries. 7. Responsible for staying abreast of all mandates, policy changes, workflow changes impacting outcomes. 8. Performs special projects as assigned by management. 9. 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. Qualifications: Requires an associate’s or bachelor’s degree (or higher) in nursing and/or a health related field OR accredited diploma nursing school. Requires a minimum of two (2) years clinical experience. Requires an active New Jersey Registered Nurse License. Prefers proficiency in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint) and Lotus Notes; prefers knowledge in the use of intranet and internet applications. Prefers basic knowledge of health care contracts and benefit eligibility requirements. Prefers experience working with
medical policy, claims review and/or appeals.