• Preferred candidate will live in the Nashville, TN area. If living in Nashville, this will be an onsite position.

• Superior candidates living outside of the Nashville area will be considered. These candidates will be able to work from home. To work from home, you must have high-speed internet (non-satellite) and a private home office.

• Work hours are 8:00 am to 5:00 pm CT. Monday through Friday.

What You Will Do:

• Performs medical claim reviews for one or more of the following: claims for medically complex services, services that require preauthorization/predetermination, requests for appeal or reconsideration, referrals for potential fraud and/or abuse, correct coding for claims/operations. Makes reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines. Determines medical necessity and appropriateness and/or reasonableness and necessity for coverage and reimbursement. Monitors process’s timeliness in accordance with contractor standards. Documents medical rationale to justify payment or denial of services and/or supplies.

• Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines.

• Participates in quality control activities in support of the corporate and team-based objectives. Provides guidance, direction, and input as needed to LPN team members. Provides education to non-medical staff through discussions, team meetings, classroom participation, and feedback. Assists with special projects and specialty duties/responsibilities as assigned by management.

What We Require You Have:

• Required Licenses and Certificates: Active, unrestricted RN licensure from the United States and in the state of hire, OR active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact NLC),

• Required Education: Associates in a job-related field OR graduate of Accredited School of Nursing.

• Required Work Experience: Two years of clinical nursing experience.

• Required Skills and Abilities: Working knowledge of word processing software. Ability to work independently, prioritize effectively, and make sound decisions. Good judgment skills. Demonstrated customer service and organizational skills. Demonstrated oral and written communication skills. Analytical or critical thinking skills. Ability to handle confidential or sensitive information with discretion.

• Required Software and Tools: Microsoft Office.

What We Prefer You Have:

• Five years clinical experience as a Registered Nurse to include one or more of the following: Prior Authorization, Medical Review, Case Management, Medical/Surgical, Utilization Review DME (Durable Medical Equipment) or Home Health experience.

• Ability to work with multiple windows based programs simultaneously.

• Intermediate Word, Excel and Outlook skills.

What We Can Do for You

• 401(k) retirement savings plan with company match.

• Subsidized health plans and free vision coverage.

• Life insurance.

• Paid annual leave – the longer you work here, the more you earn.

• Nine paid holidays.

• On-site cafeterias and fitness centers in major locations.

• Wellness programs and healthy lifestyle premium discount.

• Tuition assistance.

• Service recognition.

• Incentive Plan.

• Merit Plan.

• Continuing education funds for additional certifications and certification renewal.

What to Expect Next

After submitting your application, our recruiting team members will review your resume to ensure you meet the qualifications. This may include a brief telephone interview or email communication with a recruiter to verify resume specifics and salary requirements. Management will be conducting interviews with the most qualifies candidates.