Relying on clinical background and utilizing Referenced Based Pricing and a Clinical Review approach he/she will review medical files / health claims, providing medical interpretation and decisions about the appropriateness of services provided by other healthcare professionals, using independent judgment, interpretation of Contracts, Medical Policy, Medical Management, Authorizations and Historical Data.

A successful candidate will have a thorough understanding of Managed care contracts and credentialing, and the ability to interact and negotiate with various providers of care/services including members of regulatory agencies, carriers, employers, nurses and health care professionals in a professional manner in order to ensure appropriate reimbursement at appropriate levels of care.

Experience with medical claims, billing, payment posting and insurance collections, is preferred, along with a broad understanding of health insurance administration processes and standard guidelines. Good negotiation and communication skills are essential. Must be fluent in English and PC literate. 

CV’s to be send at hrhealthinsurance@gmail.com 

 

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