21 days old

Medical Management Nurse II

Capital BlueCross
Harrisburg, PA 17101
  • Job Code

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 managing requests for medical necessity review, applying Milliman criteria to requests, researching new and experimental procedures, interpreting Capitals Medical Policies and current Medicare Guidelines and doing so within the framework of established policy and procedures of Capitals Clinical Management Department.

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.

Ability to operate 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.

Demonstrates openness, flexibility, problem solving, patience, and tact when dealing with Members, family and staff. Excellent written and oral communication skills.

Capable of working independently as well as part of a team.

Registered Nurse with an active unrestricted Pennsylvania license.

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

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.

Posted: 2020-03-14 Expires: 2020-04-12
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Medical Management Nurse II

Capital BlueCross
Harrisburg, PA 17101

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