Job Description:

This position resides in the Medical Management Department. Included in this position are four aspects of medical necessity review: Pre-Authorization, Concurrent Review, Medical Claims Review and Appeals.

This position is responsible for:
Accurately issuing authorizations for appropriate procedures and diagnoses requiring preauthorization, using Milliman criteria, Medicare guidelines and medical policies within the established policies of the Clinical Management Department.

Identifying authorization requests that do not meet established guidelines, researching and obtaining all necessary clinical and historical information, and reviewing with the Medical Director for determination.

JOB REQUIREMENTS 

• Licensed Practical Nurse with an active unrestricted Pennsylvania license.


• Five (5) years clinical experience working in an acute care hospital or other appropriate clinical setting.


• Knowledge of URAC and NCQA standards for case management organizations and CMSA Standards of Practice for Case Management, Act 68, NCQA, CMS and ERISA.


• Knowledge of managed care principles and emerging health treatment modalities.


• Experience operating a personal computer (PC), including proficiency in Word, Access, Excel and Outlook and Clinical databases utilizing a talk and type method of documentation.


• Ability to interact with other departments, as needed, to advise, educate and/or direct members to appropriate services.


• Ability to apply critical thinking skills to daily activities.


• Capability to work independently as well as part of a team.

Capital BlueCross is an independent licensee of the BlueCross BlueShield Association. We are an equal opportunity/affirmative action employer and do not discriminate on the basis of race, color, religion, national origin, gender, sexual orientation, gender identity, age, genetic information, physical or mental disability, veteran status, or marital status, or any other status protected by applicable law. 

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