An independent subsidiary of WellPoint, Inc, National Government Services (NGS) is one of the largest Medicare contractors in the country, serving nearly 200,000 providers and suppliers and over 20 million customers with Medicare in 20 states and five U.S. territories.
Bring your expertise to our innovative culture where you will have the opportunity to make a difference in people’s lives, and to take your career further than you can imagine.
Our Nurse Reviewer NGS Ld is responsible for serving as a team lead for nursing staff who collaborate with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources for the most complex or elevated medical issues. Ensures medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting by utilizing the applicable medical policy and industry standards, accurately interpreting benefits and managed care products, and steering members to appropriate providers, programs or community resources. Works with medical directors in interpreting appropriateness of care and accurate claims payment. May also manage appeals for services denied.
Primary duties may include, but are not limited to:
Requires an AS/BS in nursing; 7 years of acute care clinical experience; or any combination of education and experience, which would provide an equivalent background. Current unrestricted RN license in applicable state(s) required. Certification in the American Association of Managed Care Nurses preferred. Must have knowledge of medical management process and ability to interpret and apply member contracts, member benefits, and managed care products. Prior managed care experience required. Medical Review Part B. Excellent knowledge of Part B mainframe system preferred. Solid understanding of the Medicare Medical Review process a must. Excellent skills in Word and Excel.
WellPoint is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine, and is a 2013 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company please visit us at www.wellpoint.com/careers. EOE. M/F/Disability/Veteran.
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