Oncology & Musculoskeletal Medical Specialist
1 month ago
Collaborate with healthcare providers and members to promote quality member outcomes, optimize benefits, and resource utilization.
Collaborate with medical directors to interpret appropriateness of care and accurate claims payment. Manage appeals for services denied.
Key responsibilities include:
- Conduct pre-certification, continued stay review, care coordination, or discharge planning for appropriateness of treatment setting reviews.
- Ensure member access to medically necessary, quality healthcare in a cost-effective setting.
- Consult with clinical reviewers and/or medical directors to ensure medically appropriate, high-quality, cost-effective care.
- Collaborate with providers to assess member needs for early identification of and proactive planning for discharge planning.
- Facilitate member care transition through the healthcare continuum and refer treatment plans/plan of care to clinical reviewers as required.
- Facilitate accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.
Requirements:
- BSN, current active unrestricted RN license to practice as a health professional in applicable state(s) of the United States.
- 2 years of acute care clinical experience or case management, utilization management or managed care experience.
- Healthcare related certification and/or Master's degree a plus.
Strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills are required.
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