NurseMedical InforSpecialistIV

The Nurse Utilization and Clinical Advisor Services Analyst IV is responsible for applying clinical expertise to drive improvements in healthcare resource utilization, cost, and quality. This role focuses on analyzing healthcare cases and claims, providing guidance on the appropriateness of care, and coordinating with clients and clinical peer reviewers to support healthcare delivery standards.

Key Responsibilities:

• Apply clinical judgment in the adjudication of cases and claims
• Review requests for denial reconsideration and appeals
• Manually price and evaluate claims, including drugs and medical supplies, for care appropriateness and coverage
• Provide input directly to clients in alignment with program policies and procedures
• Collaborate with clinical peer reviewers to resolve cases and claims
• Perform additional duties as assigned and ensure compliance with all company policies and standards

Qualifications and Experience:

• Education: Bachelor’s degree or equivalent experience in a relevant field
• Licensure: Active Registered Nurse (RN) license in good standing
• Experience: Prior experience in a healthcare or medical services role, preferably involving claims or case review, is required
• Skills:
  • Strong analytical skills to assess and resolve straightforward problems
  • Ability to interpret program policies and procedures effectively
  • Proficiency in explaining complex information to others in clear, straightforward situations