Remote Post Service Review RN – Sr. – California

• Conducts clinical review of claims for medical necessity, coding accuracy, medical policy. compliance and contract compliance.
• Verify insurance eligibility.
• Review claims against FEP Benefits and policy to determine if claim can be approved, denied, or if we need additional information to make a determination.
• Utilize Medical Director to assist with medical necessity determinations.

Qualifications & Requirements:

• Active CA RN License
• Bachelor’s degree or equivalent experience
• Previous post service review experience
• Previous utilization management, prior authorization or concurrent review experience