QUALIFICATIONS:

• Bachelor’s Degree in Nursing with an active and valid license (PHRN/USRN)
• At least 2 years of experience in Utilization Management and medical necessity approval and denials
• Must have at least 1 or 2 years in a managerial position handling leaders/ TLs/ Supervisors
• With experience in training and quality management, preferably 5 years (Minimum 2 years required)
• Experience in a hospital setting or other clinical environment, such as BPO/CPO
• Familiarity with Medicare rules & regulations and guidelines, including coverage criteria and coding principles
• Experience in handling appeals, utilization review, or related healthcare management functions
• Excellent verbal and written communication skills are essential for preparing appeal arguments and communicating with different stakeholders
• Ability to analyze complex medical information and identify relevant clinical issues
• Have knowledge and experience in InterQual, NCQA and CMS.
• Willingness to work on-site with flexible schedules, including US hours and holidays
• Must not be a current or former employee of Concentrix