Nurse Case Management Lead Analyst

Nurse Case Management Lead Analyst-Nurse Clinician - Accredo

Job Description Summary

The Nurse Clinician - RN is responsible for reviewing escalated clinical criteria reviews for providers, members and patient client advocates within the Prior Authorization/Utilization Management department.

Identify and track trends for analytics reporting to ensure clinical criteria program integrity.

Maintain a professional and ethical behavior at all times as outlined by the Nurse Practice Act and applicable company policies.

JOB DUTIES:


* Conduct criteria reviews for commercial payers, Medicare, and Medicaid


* Provide prior authorization assistance, and denial appeal assistance


* Prepare and write medical necessity appeal letters for claim denials for commercial and government payers.


* Support all aspects of Patient Access and Revenue Cycle Management (PARCM), including clearance and reimbursement for multiple Therapeutic Resource Centers.

QUALIFICATIONS


* Active, unencumbered Registered Nurse (RN) license in Pennsylvania


* High School Diploma or GED, plus 8+ years of relevant RN experience; or


* 5+ years of relevant RN experience with an ASN degree; or


* 2+ years of relevant RN experience with a BSN degree


* Case management experience preferred


* 5+ years of experience is preferred in prior authorization or utilization review and appeals


* Demonstrated proficiency with Microsoft Office software; basic database navigation


* Ability to multitask in both PC/Phone related tasks


* Ability to build strong working relationships with colleagues and customers


* Strong time management skills and the ability to prioritize work and meet deadlines


* Excellent verbal and written communication skills


* Ability to work Monday-Friday, 8am-5pm, Eastern time


* Adequate home internet access will be required in this role

TECHNICAL SKILLS:.



* Case management experience preferred


* 5+ years of experience is preferred in prior authorization or utilization review and appeals


* Demonstrated proficiency with Microsoft Office software; basic database navigation


* Ability to multitask in both PC/Phone related tasks

SOFT SKILLS:.



* Ability to build strong working relationships with colleagues and customers


* Strong time management skills and the ability to prioritize work and meet deadlines


* Excellent verbal and written communication skills


* Ability to work Monday-Friday, 8am-5pm, Eastern time


* Adequate home internet access will be required in this role

COMPETENCIES:



* Communicates Effectively


* Collaborates


* Customer Focus


* Decision Quality


* Nimble Learning

If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload.

For this position, we anticipate offe...