**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 knowledge and experience in the field. + Will acquire higher-level knowledge and skills. + Develops 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.