This job will have the following responsibilities:
- 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