• This position is responsible for conducting medical management and health education programs for customers on government health care programs. • Accountabilities include gathering, analyzing and providing date for regulatory reports. • This position will represent the company to members.

• This position is responsible for conducting medical management and health education programs for customers on government health care programs. • Accountabilities include gathering, analyzing and providing data for regulatory reports. • This position will represent the company to members.

• RN working in the insurance or managed care industry using medically accepted criteria to validate the medical necessity and appropriateness of the treatment plan. • Performing accurate and timely medical review of claims suspended for medical necessity, contract interpretation, pricing; • Initiating and/or responding to correspondence from providers or members concerning medical determinations. • Knowledge of accreditation, i.e. URAC, NCQA standards and health insurance legislation. • Awareness of claims processes and claims processing systems. • PC proficiency to include Microsoft Word and Excel and health insurance databases. • Verbal and written communication skills with the ability to communicate to physicians, members and providers and compose and explain document findings. • Organizational skills and prioritization skills.

• This position is responsible for conducting medical management and health education programs for customers on government health care programs. • Accountabilities include gathering, analyzing and providing data for regulatory reports. • This position will represent the company to members.