Description:

- Responsible for meeting all State and Federal regulations as well as the clients mandates related to claims and preauthorization processing

- Responsible for accurate and timely medical review of claims and preauthorization's

- Responsible for accurate and timely medical review of customer service inquirers about claims and preauthorization's

- Responsible for completion of special projects; examples may include training new hires, provider outreach, project work, peer mentor, new system implementation and system testing

- 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

- 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, a medical directors and pharmacists to ensure medically appropriate, high-quality, cost-effective care, promote positive member outcomes, effective use or resources, optimize member benefits and support business initiatives

Additional Skills & Qualifications:

- Associate's degree in nursing or certified practical nursing and three years of clinical experiences in a health care setting

- Must hold a current, unrestricted RN license, or a compact license from states previously mentioned

- 2 years of exp in medical review or UM

About Actalent

Actalent is a global leader in engineering and sciences services and talent solutions. We help visionary companies advance their engineering and science initiatives through access to specialized experts who drive scale, innovation and speed to market. With a network of almost 30,000 consultants and more than 4,500 clients across the U.S., Canada, Asia and Europe, Actalent serves many of the Fortune 500.

Diversity, Equity & Inclusion

At Actalent, diversity and inclusion are a bridge towards the equity and success of our people. DE&I are embedded into our culture through:

Hiring diverse talent Maintaining an inclusive environment through persistent self-reflection Building a culture of care, engagement, and recognition with clear outcomes Ensuring growth opportunities for our people

The company is an equal opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.

If you would like to request a reasonable accommodation, such as the modification or adjustment of the job application process or interviewing process due to a disability, please email actalentaccommodation@actalentservices.com for other accommodation options.