Job Track Description:

• Requires formal education and relevant expertise in a professional, sales, or technical area.

• Performs technical-based activities.

• Contributes to and manages projects.

• Uses deductive reasoning to solve problems and make recommendations.

• Interfaces with and influences key stakeholders.

• Leverages previous knowledge and expertise to achieve results.

• Ability to complete work self-guided.

• College or university degree required.

General Profile

• Requires knowledge and experience in the field.

• Will acquire higher-level knowledge and skills.

• Develops an understanding of the company, processes, and customers.

• Uses existing procedures to solve routine or standard problems.

• Receives moderate guidance and direction from others.

Functional Knowledge

• Requires expanded conceptual understanding of theories, practices, and procedures.

Business Expertise

• Uses an understanding of key business drivers to accomplish work.

Impact

• Impacts a team, by example, through the quality service and information provided

• Works within guidelines and policies.

Leadership

• No supervisory responsibilities.

• Provides informal guidance to new team members.

Problem Solving

• Uses existing procedures to solve standard problems.

• Examines information and standard practices to make judgments.

Interpersonal Skills

• Exchanges complex information and ideas effectively.

Responsibility Statements

• Applies medical judgment to adjudication of cases/claims.

• Reviews requests for denial reconsideration and appeals.

• Manually price and review claims for appropriateness of care or coverage.

• Works directly with the client to provide input under program policy or procedural requirements.

• Coordinate with clinical peer reviewers for case/claim resolution.

• Performs other duties as assigned.

• Complies with all policies and standards.

Additional Information

• Requires Registered Nurse license in good standing.