Associate Consultant

BSc/MSc nursing with NCLEX certification and active US RN license NCLEX Certified Nurse with 5+ years of clinical experience

Responsibilities

Senior SME Skillset: Training, Data Management and reporting, Quality Tools, Descriptive Analysis, New project Implementation

• Perform medical necessity and clinical reviews of authorization requests to determine medical appropriateness of care in accordance with regulatory guidelines and Standard Operating procedures
• Clinical knowledge and ability to analyze authorization requests and determine medical necessity of service preferred.
• Good understanding of US healthcare business
• Knowledge of utilization management processes (preferred)
• Ability to understand Milliman guidelines (preferred)
• Knowledge of managed care, acute care, emergency room, cardiology, radiology, etc
• Understanding of ICD and CPT codes

Requirements

Primary skills: Operations->Clinical Data Management Microsoft Word, Excel, Computer navigation, typing skills, effective communication skills, both verbal and written

Additional: • Ability to work with clients to identify business challenges and contribute to client deliverables by refining, analyzing, and structuring relevant data • Awareness of latest technologies and trends • Logical thinking and problem solving skills along with an ability to collaborate • Ability to assess the current processes, identify improvement areas and suggest the technology solutions • One or two industry domain knowledge