BASIC FUNCTION:

This position is responsible performing initial, concurrent review activities; discharge care coordination for determining efficiency, effectiveness and quality of medical/surgical services and serving as liaison between providers and Medical and Network Management Divisions. This position conducts on-site reviews and assessments, reviews service requests, collects clinical and non-clinical data, verifies eligibility, determines benefit levels in accordance to contract guidelines, prepares reports on quality of care, identifies and reports cases, and provides information regarding utilization management requirements and operational procedures to members, providers and facilities.



JOB REQUIREMENTS:

* Registered Nurse (RN) with valid, current, unrestricted license in the state of operations.

* 3 years of clinical experience in physician office, hospital/surgical setting or health insurance company.

* Knowledge of medical terminology and procedures.

* Verbal and written communication skills.