Executives

Nurse Level 1/2A

Job Group Healthcare

Job Title Nurse Level 1/2A

Functional Title Associate Clinical Claims Review

Exemption Status Non-Exempt

Family Summary/Mission

Provide comprehensive clinical review of complaints and appeals filed by providers with the use of appropriate resources and guidelines to ensure cost effective delivery of health service

Position Summary/Mission

• Supports identification and review of appropriate case types in compliance with the clinical guidelines
• Promotes/supports quality effectiveness of Healthcare Services.

Fundamental Components & Physical Requirements (include but are not limited to)

• 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.
• Condenses complex information into a clear and precise clinical picture while working independently.
• Data gathering requires navigation through multiple system applications.
• Utilizes client systems to build, research and enter member information
• Applies clinical guidelines in determining clinical decisions
• Experience in patient management in clinical setting is a requirement to help with clinical understanding
• Accurately applies review requirements to assure case is reviewed by a practitioner with clinical expertise for the issue at hand.

Documentation and Communication

• Maintains accurate and complete documentation of required information that meets risk management,

regulatory, and accreditation requirements

• Promotes communication, both internally and externally to enhance effectiveness of medical management services (e.g. Claim Administrators, Plan Sponsors, and 3rd party payers as well as Member, Family, and Healthcare Team Members respectively)
• Protects the confidentiality of member information and adheres to company policies regarding

confidentiality

• Evaluates documentation/information to determine compliance with clinical policy, regulatory and

accreditation guidelines.

• Reports audit or clinical findings to appropriate staff or others in order to ensure appropriate outcome

and/or follow-up for improvement as indicated.

• Sedentary work involving significant periods of sitting, talking, hearing and keying.
• Work requires visual acuity to perform close inspection of written and computer generated documents as well as a PC monitor.
• Working environment includes typical office conditions.
• Ability to understand and interpret clinical laboratory results and familiarity with clinical conditions and its management is required