3850810-Executives
Core
Review complaints and appeals filed by providers to ensure cost-effective delivery of health services.
Role type
Associate Healthcare Academy (Nurse Level 1/2A)
Builds
Clinical determinations and recommendations for healthcare claims
Domain
Healthcare / Insurance
Required skills
Clinical policy application, documentation review, data gathering, system navigation, clinical guidelines interpretation, audit reporting, confidentiality management
Preferred skills
Experience in patient management in clinical setting, ability to interpret clinical laboratory results
Technologies
Client systems, PC monitor, multiple system applications
Responsibilities
Review documentation and evaluate potential quality of care issues, condense complex information into clear clinical pictures, apply clinical guidelines to determine clinical decisions, maintain accurate documentation, communicate with internal and external stakeholders, report audit or clinical findings