Specialized Recruiting. Temporary Staffing. Managed Services. 800 876 2314


Medical Services Nurse Specialist

Employment Type Permanent
Field of Work Clinical/Medical

 

Position Summary

The Nurse Specialist (LVN, LPN, RN) is directly accountable to the Manager, Medical Services for the preparation and review of all special clinical files to ensure accuracy and compliance. They are expected to function with minimal direct supervision but guidance will be available. The candidate must possess solid writing skills as they will be responsible for making all edits and providing written clinical explanations to clients as necessary. The Individual will collaborate with the Medical Director and the Medical Reviewers/MD for clarity regarding medical terminology, consistency of CPT Codes, and guidelines. Other aspects of the job are special projects involving claims review and medical necessity determinations.

Position Responsibilities

  • Collaborate with the Medical Directors in the decision making process regarding clinical reviews.
  • Strong customer service focus and excellent ability to effect one-call resolution of problem situations.
  • Maintains contact and communicates with provider office or other organizations to apprise them of claim activity, claim status and UM activity, as relevant.
  • Acts as clinical resource/educator with provider office on an ongoing basis in order to maximize customer service and highest quality of care.
  • Demonstrated knowledge of UM and claim coding to support discussions with providers.
  • As needed may serve as designated liaison with specific clients and/or for specific services or programs.
  • All other duties as assigned.

Position Requirements

  • Nursing degree with current licensure
  • Strong knowledge of medical terminology, preferably in claims and utilization management.
  • 3+ years of clinical experience
  • Previous experience in a managed care setting a plus
  • Strong verbal and written communication skills
  • Ability to multitask.
  • Must have excellent editing skills.
  • Demonstrated ability to work independently
  • Requires ability to work in a team setting
  • Computer literate with respect to MC Office Suite
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