- Conduct reviews up to and including the appeal level. Involving chart screen, compiling regulatory guidance, researching insurer requirements, completing electronic worksheets, and preparing final determinations.
- Act as a resource for the administrative and clinical staff in training, problem-solving, and clarifying determinations.
- Provide technical assistance and conduct/participate in staff hurdles.
- Participate in collaborative training.
- Knowledge and experience with electronic medical records.
- Ability to oversee, problem solve, and work collaboratively with peers, medical, analytical, and administrative support staff.
- Excellent written and verbal skills.
- Ability to work independently with little supervision.
- Ability and desire to be flexible, innovative, and creative.
- Ability to meet deadlines in a time-sensitive environment.
- New York Licensed Registered Nurse, required.
- A bachelor's degree in nursing or graduate of an approved Registered Professional Nurses training program, required.
- Legal Nurse Consultant Certification, required.
- Three (3) years' experience in Med-Legal review setting, required.
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Legal Nurse - North New Hyde Park, United States - IPRO
Description
As the Legal Nurse, you will complete the full spectrum of activities related to State and Federal Independent Dispute Resolution (IDR) case determinations. Conducting clinical level review, prior authorization, and disputed benefits review, supporting Medical Review Analysts, and Physician Consultants to ensure an appropriate and accurate process. Duties include but are not limited to:
Potential opportunity for Hybrid option (3 days in office 2 days home) considered after initial orientation/training period.
QUALIFICATIONS :
EDUCATION & EXPERIENCE :
