Location
Kochi | India
Job description
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.
Organizational Relationships Reports To : Assistant Manager Supervises : N/A Skills Technical Skills - Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding
- Able to research on updated medical information which are relevant to the reviews being done and integrate it to the referrals being made to the MD's
Process Specific Skills - Written Clinical discussion skills
- Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer.
- Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor.
- Ability to multitask, prioritize and effectively adapt to a fast paced changing environment
- Typical office working environment with productivity and quality expectations
Soft Skills (Desired)- Effective communication skills, both verbal and written.
Preferably a C1 CEF level Soft Skills (Minimum) Education Requirements - B.S. Nursing Graduate
- US Registered Nurse with current unrestricted state licensure
Work Experience Requirements - 2 years Clinical Experience
- Practical experience in areas of acute care, emergency room, cardiology, radiology, etc
- Managed Care experience preferred
Annexure Acknowledgement (acknowledge that the information contained in this document is factual and complete)
___________________________________ ___________________________________________ ____________________________
Candidate Supervisor/Manager Date
Job tags
Salary