Responsible for reviewing and analyzing institutional and professional claims and supporting medical documents to determine medical necessity of billed services and benefits payable according to established guidelines. Primary duties may include, but are not limited to: Reviews, analyzes and renders determinations on requests from the providers and beneficiaries for reconsideration of previously rendered medical decisions relating to claims issues. Requires a current Philippines RN license; 4 years of health care experience; or any combination of education and experience, which would provide an equivalent background. Current unrestricted RN license in applicable state(s) as required.
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