Medical Review Specialist – I

Role Overview

• Responsible for meeting all State and Federal regulations
• Responsible for accurate and timely medical review of claims and preauthorization's
• Responsible for accurate and timely medical review of Customer Service inquiries about claims and preauthorization's
• Responsible for determining availability of benefits according to company contracts, endorsements and medical policy
• Responsible for determining member eligibility prior to medical review
• Responsible for fostering a constructive relationship with all departments within BCBSNE
• Responsible for maintaining professional licensure and practicing within the scope of licensure
• Responsible for collaborating and consulting with healthcare providers, members, and internal team of clinical support specialists, nurses, physicians, medical directors and pharmacists

Requirements

• Associate degree in nursing or Certified Practical Nurse
• Three (3) years clinical experience in a health care setting
• Active, current, and unrestricted Registered Nurse or Licensed Practical Nurse license from the state of Nebraska or a state in the consortium in which Nebraska participates

Benefits

• Health insurance
• Professional development opportunities