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Function is responsible for performing pre-service clinical coverage review of services that require notification, using applicable benefit plan documents, evidence-based medical policy and nationally recognized clinical guidelines and criteria. Determines medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination. Conduct Non-Clinical Research to Support Determinations. Determine that the case is assigned to the appropriate team and health plan for review (e.g., Medicare, Medicaid, Commercial, Dual Special Needs Plan) Review Existing Clinical Documentation. Review/interpret clinical/medical records submitted from provider (e.g., office records, test results, prior operative reports) Make Final Determinations Based on Clinical and Departmental Guidelines. Understand and adhere to applicable legal/regulatory requirements (e.g., federal/state requirements, HIPAA, CMS, NCQA/URAC accreditation) Achieve and Maintain Established Productivity and Quality Goals. Adhere to relevant quality audit standards in performing reviews, making determinations and documenting recommendations. Your role is critical in allowing our members, families, facilities and health professionals to have greater confidence in the exceptional care we provide. And for you, an everyday opportunity to do your life’s best work.SM


  • Valid and unrestricted USRN license preferred
  • Holders of Expired and Non-Mainland USRN license are welcome to apply
  • A minimum of 1 year hospital experience in a critical care unit (ICU/Medical-Surgical/Telemetry)
  • Clinical competence in understanding hospital care and care coordination

Skills Requirement:

  • Medical/Surgical Asepsis
  • Intensive Care Unit (ICU)
  • Telemetry


  • Market Total Rewards Package
  • Permanent Work From Home, Computer/Laptop Provided by the Company
  • Up to 200K Sign On Bonus! Terms and Conditions Apply
  • Retirement Plan
  • Medical Plan (HMO) from Day 1 of employment
  • Dental, Medical, and Optical Reimbursements
  • Life and Disability Insurance
  • Paid Time-Off Benefits
  • Sick Leave Conversion
  • Tuition Fee Reimbursement
  • Employee Assistance Program (EAP)
  • Annual Performance Based Merit Increases
  • Employee Recognition
  • Training and Staff Development
  • Employee Referral Program
  • Employee Volunteerism Opportunity
  • All Mandatory Statutory Benefits
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