Clinical Data Services Representative

Job Title : Registered Nurse (H&PS)

Work Location : Austin, TX (Local Candidates Preferred - Remote)

Offering Description :

MUST BE ABLE TO WORK 10A to 7P SHIFT. No direct patient care. 8-hour shifts unless OT is needed and approved. Will have a shift between 7am and 7pm, so must be available for all shifts between that time.

Process Description :

RN conducts pre-service, concurrent retrospective reviews. Collaborate with healthcare providers, promote quality member outcomes, optimize member benefits, promote effective use of resources. Ensure medically appropriate high-quality cost-effective care through assessing medical necessity of outpatient services, out of network services, and appropriateness of treatment setting within scope of professional limitation.

Skills Description :

• Utilize the applicable rules of the Texas Administrative Code (TAC).
• Review Medical Necessity requirements.
• Would be nice to have skills :
• Microsoft Word
• Excel
• Work and Excel

Roles and Responsibilities :