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PHRN - NURSE UTILIZATION AND CLINICAL ADVISOR SERVICES ANALYST II
Job Track Description:
- Requires formal education and relevant expertise in a professional, sales, or technical area.
- Performs technical-based activities.
- Contributes to and manages projects.
- Uses deductive reasoning to solve problems and make recommendations.
- Interfaces with and influences key stakeholders.
- Leverages previous knowledge and expertise to achieve results.
- Ability to complete work self-guided.
- College or university degree required.
- Requires knowledge and experience in the field.
- Will acquire higher-level knowledge and skills.
- Develops an understanding of the company, processes, and customers.
- Uses existing procedures to solve routine or standard problems.
- Receives moderate guidance and direction from others.
- Requires expanded conceptual understanding of theories, practices, and procedures.
- Uses an understanding of key business drivers to accomplish work.
- Impacts a team, by example, through the quality service and information provided
- Works within guidelines and policies.
- No supervisory responsibilities.
- Provides informal guidance to new team members.
- Uses existing procedures to solve standard problems.
- Examines information and standard practices to make judgments.
- Exchanges complex information and ideas effectively.
- Applies medical judgment to adjudication of cases/claims.
- Reviews requests for denial reconsideration and appeals.
- Manually price and review claims for appropriateness of care or coverage.
- Works directly with the client to provide input under program policy or procedural requirements.
- Coordinate with clinical peer reviewers for case/claim resolution.
- Performs other duties as assigned.
- Complies with all policies and standards.
- Requires Registered Nurse license in good standing.