QUALIFICATIONS:

• Bachelor’s Degree in Nursing with an active and valid license in USRN
• Must have at least 2 years of experience in utilization management and medical necessity approvals and denials
• With experience in Virtual or classroom training
• Must have at least 1 year of InterQual process experience
• Minimum of 1 to 2 years of experience in a trainer role
• With BPO/CPO experience
• Experience in a hospital setting or other clinical environment/ contact center setting
• Familiarity with Medicare rules and 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
• Ability to analyze complex medical information and identify relevant clinical issues
• Willingness to work on-site with flexible schedules, including US hours and holidays