PHRN - Nurse Utilization and Clinical Advisor Services Analyst II

Job Track Description:

• Requires formal education and relevant expertise in a professional, sales, or technical area.
• Performs technical-based activities.
• Contributes to and manages projects.
• Uses deductive reasoning to solve problems and make recommendations.
• Interfaces with and influences key stakeholders.
• Leverages previous knowledge and expertise to achieve results.
• Ability to complete work self-guided.
• College or university degree required.

General Profile

• Requires an understanding of the company, processes, and customers.
• Uses existing procedures to solve routine or standard problems.
• Receives moderate guidance and direction from others.

Functional Knowledge

• Requires expanded conceptual understanding of theories, practices, and procedures. 

Business Expertise

• Uses an understanding of key business drivers to accomplish work.

Impact

• Impacts a team, by example, through the quality service and information provided
• Works within guidelines and policies.

Leadership

• No supervisory responsibilities.
• Provides informal guidance to new team members.

Problem Solving

• Uses existing procedures to solve standard problems.
• Examines information and standard practices to make judgments.

Interpersonal Skills

• Exchanges complex information and ideas effectively.
• Responsibility Statements
• Applies medical judgment to adjudication of cases/claims.
• Reviews requests for denial reconsideration and appeals.
• Manually price and review claims for appropriateness of care or coverage.
• Works directly with the client to provide input under program policy or procedural requirements.
• Coordinate with clinical peer reviewers for case/claim resolution.
• Performs other duties as assigned.
• Complies with all policies and standards.

Additional Information

• Requires Registered Nurse license in good standing.