Medical Policy Specialist - Registered Nurse

General Job Description:

Registered Nurse to review patient medical documentation and make on-line payment determinations for claims and prior authorizations that require medical expertise.  Decisions are based on State Medicaid Policy and nursing experience.

 

ResponsibilitiesReview requests submitted by providers through a Lotus Notes Fax Tracking systemUse MMIS and the exceptions database to review requests and approve or deny them based on Medicaid policyDetermine the medical necessity of exception requests based on recipient need for a service/item that is not covered in the regular Medicaid program.  Determinations are made on an individual, case by case basis.Candidate may be required to review exception requests with DMS Clinical Services staff (formally Exceptions Unit) at an off-site location.  Work Monday through Thursday, 7:00 am to 5:30 pm with half hour lunch.  Flexibility in work week/hours may be possible once initial training period is completed. Overtime may be required due to increase in workload or contractual obligations.Position is revenue generating.



Qualifications/Education Required:Candidate must be a registered nurse who has graduated from an accredited four year college or university with a Bachelor's degree in Nursing and must have had at least one (1) year of professional nursing experience OR have graduated from a recognized school of nursing and must have had at least two (2) years of professional nursing experience. A varied nursing background (doctor's office, hospital, and specialty) and experience is preferred.



Equal Opportunity Employer