Registered Nurse

Integrated Resources Inc.; Hopewell (NJ); On-site; USD 60,000 - 80,000; Full time

Job summary

Integrated Resources Inc. is looking for a Medical Policy Analyst to handle medical policy determinations for claims and ensure efficient utilization of benefits. The role involves reviewing medical cases, communicating with claim teams, and adhering to regulations, requiring strong analytical skills and a relevant degree.

Qualifications

• Requires an associate's or bachelor's degree in nursing or related field.
• Minimum two (2) years of clinical experience.

Responsibilities

• Provide timely responses to inquiries from the claim policy teams.
• Prepare cases for Medical Director Review and identify opportunities for policy revisions.
• Manage assigned inventory, documenting production and follow-through.

Skills

Analytical skills

Communication

Knowledge of laws and regulations

Education

Associate's or Bachelor's degree in Nursing

Accredited Diploma Nursing School

Job description

Integrated Resources, Inc., is led by a seasoned team with combined decades in the industry. We deliver strategic workforce solutions that help you manage your talent and business more efficiently and effectively. Since launching in 1996, IRI has attracted, assembled and retained key employees who are experts in their fields. This has helped us expand into new sectors and steadily grow.

Job Description

This position is responsible for the medical policy determination of claims/cases consistent with Plan Medical Policy to ensure appropriate and efficient utilization of benefits. Performs duties as assigned by management.
Responsibilities:
1. Provide timely and accurate responses to inquiries from the claim policy teams in relation to courtesy pre-determination requests, claims pending for medical review and appeal inquiries.
2. Prepares cases for Medical Director Review and or outside consultant review and response where appropriate.
3. Responsible for processing pends for which the Medical Policy Inquiry Resolution team has authority to do so.
4. Identifies opportunities for development of or revisions to Client Medical Policy based on case review.
5. Responsible for identifying areas and pursuing solutions where medical policy is not being applied correctly in claim payment outcome.
6. Responsible for managing inventory assigned, documenting production and follow through on all assigned inquiries.
7. Responsible for staying abreast of all mandates, policy changes, workflow changes impacting outcomes.
8. Performs special projects as assigned by management.
9. Demonstrates knowledge and understanding of the laws regulations and policies that pertain to the organization unit's business and conforms to these laws, regulations and policies in carrying out the accountabilities of the job.
10. Completes other assigned functions as requested by management.

Qualifications

1. Requires an associate's or bachelor's degree (or higher) in nursing and/or a health related field OR accredited diploma nursing school.
2. Requires a minimum of two (2) years clinical experience.