USRN (US Registered Nurse)
Entry Level / Junior, Apprentice
Description
Qualifications
- Must have an active NCLEX License (US Registered Nurse) and PRC License (Philippine Registered Nurse.
- Must have at least 3 months of clinical experience as a Registered Nurse
- Must be willing to work at the office or WFH based on company business needs.
- Must have good computer skills and can type at least 25wpm.Must have a stable active hard wired internet connection at home.
Job Responsibilities
- Review service requests to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits and contracts.
- Route cases to client medical staff for further review when a service or admission does not meet medical necessity, place of service, or benefit criteria.
- Work with clinical reviewers and medical directors in interpreting appropriateness of care and conducting PSCCR claims review utilizing the member’s benefit contract and health plan guidelines.
- Process incoming requests, collection of information needed for review form providers.
- Determine contract and benefit eligibility, obtain intake demographic information from callers and/or faxes.