Responsible for providing clinical and technical support for the assigned area(s). * Assist with the design, development, modification, testing, implementation and maintenance of assigned systems related to medical reviews for claims and inquiries. * Assist teams with the resolution of problems, conduct special assignments as requested and populate and interpret reports and/or analysis documenting the results with recommendations to management. * Troubleshoot problems, identify defects, trends, procedural practices and submit recommendations. May be required to interface with other areas, either internally or externally, to resolve problems. * Compile and analyze data and produce routine and non-routine reports, presentations, letters, and communications in compliance with local, state and federal regulations and NCQA accreditation standards. * Assist personnel (both internal and external) by answering questions, supplying information and training. * Accurately assess health needs in a manner consistent with current nursing standards and practice in order to provide appropriate clinical recommendations. * Utilize knowledge of approved resources, programs, products, and tools to provide appropriate review of services and preauthorization's based on medical necessity. * Collaborate with peers and project and team members. * Participate in continuous improvement efforts resolving issues that impact operations, business workflows, processes and strategies. * Utilize up-to-date technical skills to navigate through electronic leadership tools and platforms; with the ability to test new tools as required. "Qualifications" * Associate's Degree in Nursing or RN Diploma required. * Two (2) to 3 years of clinical experience including Medical Surgical. * Demonstrated clinical knowledge and experience relative to patient care and health care delivery processes. * Registered Nurse with current unrestricted state of Michigan license required.Excellent written and verbal communication skills. * Working knowledge of PC applications. Able to comprehend and use other systems and applications used within the assigned department. * Other related skills and/or abilities may be required to perform this job. * Work individually and in a diverse team environment. Departmental Preferences: * Proficiency in Microsoft 365 and BCBSM Systems is preferred. * Experience with Medical Necessity Reviews/Utilization Management is preferred. All qualified applicants will receive consideration for employment without regard to, among other grounds, race, color, religion, sex, national origin, sexual orientation, age, gender identity, protected veteran status or status as an individual with a disability.
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