Nebraska Licensed Medical Review Specialist

Job Summary

A company is looking for a Medical Review Specialist I, responsible for performing medical reviews to ensure compliance with regulations and policies.

Key Responsibilities

• Ensure compliance with State and Federal regulations, as well as company mandates related to claims and preauthorization processing
• Perform accurate and timely medical reviews of claims, preauthorizations, and customer service inquiries
• Collaborate with healthcare providers and internal teams to promote high-quality, cost-effective care and optimize member benefits

Required Qualifications, Training, and Education

• Associate degree in nursing or Certified Practical Nurse with three years of clinical experience in a healthcare setting
• Current, unrestricted Registered Nurse or Licensed Practical Nurse license from Nebraska or a participating state
• Bachelor's degree in a healthcare field is preferred
• Certification in Managed Care is a plus
• Experience in medical review or utilization management is advantageous