Executives

Job Description

Position Title, Responsibility Level

Nurse Level 2B or 3 / 4

Function

UM Nurse Associate

Reports to

Assistant Manager

Permanent/ Temporary

Permanent

Span of Control

Location

Manila / Cebu / Iloilo/Kochi

Basic Function

Provision of high quality review for inpatient and/or outpatient precertification/ preauthorization.

Essential Functions

. Provide review of precertification requests for medical necessity basing from clinical policy guidelines

. Responsible for checking of eligibility and benefits of the member's coverage

. Data gathering of additional information needed in reference to the guidelines, through effective communication with network providers as well as members

. Give unbiased recommendation for medical necessity based on medical records provided by the requesting parties

. Independently work with Medical Directors on referrals of cases that would not meet set guidelines upon initial review

. Review appropriate length of hospital stay utilizing Milliman Care Guidelines

. Efficient and timely review of cases with adherence to standards for urgent and non-urgent turnaround time

. Proactively offer peer to peer review and appeals process for reconsideration on case denials

. Maintain privacy of records for all related information to members

. Establish effective multitasking and task prioritization

. Work comprehensively within the turnaround time

Primary Internal Interactions

• Coaching and team meetings with supervisors and managers

Primary External Interactions

• Reviews documentation and evaluates potential quality of care issues based on clinical policies and benefit determinations.
• Considers all documented system information as well as any additional records/data presented to develop a determination or recommendation.
• Data gathering requires navigation through multiple system applications.
• Staff may be required to contact the providers of record, vendors, or internal Aetna departments to obtain additional information.
• Evaluates documentation/information to determine compliance with clinical policy, regulatory and accreditation guidelines.
• Accurately applies review requirements to assure case is reviewed by a practitioner with clinical expertise for the issue at hand.
• Commands a comprehensive knowledge of complex delegation arrangements, contracts (member and provider), clinical criteria, benefit plan structure, regulatory requirements, company policy and other processes which are required to support the review of the clinical documentation/information.
• Pro-actively and consistently applies the regulatory and accreditation standards to assure that activities are reviewed and processed within guidelines.