Nurses (indian Registered & US Registered)

Nurses (indian Registered & US Registered)

2COMS Consulting Private Limited
1-6 years
450000 - 950000 INR

Job Description

USRN :(US Registered Nurses)
Qualifications :
  • US registered nurse with 1-2 years of clinical experience
  • Practical experience in areas of acute care, ER, cardiology, radiology, etc.
  • Managed care experience preferred
  • Education and Certification Requirements
  • BSc Nursing Graduate, US registered nurse with current unrestricted state licensure

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.
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, Aetna 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.
Condenses complex information into a clear and precise clinical picture while working independently.
IRN :(indian Registered Nurses)
Job Group Healthcare
Family Name Care Management
Fundamental Components & Physical Requirements (include but are not limited to)
Note: * denotes essential functions
Member Identification
- Performs intake of calls from members or providers regarding services via telephone, fax, EDI (*)
- Utilizes eTUMS and other Aetna system to build, research and enter member information (*)
- Screens requests for appropriate referral to medical services staff (*)
- Approve services that do not require a medical review in accordance with the benefit plan (*)
- Performs non-medical research including eligibility verification, COB, and benefits verification (*)
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 confidentiality of member information and adheres to Aetna policies regarding confidentiality (*)
- Communicate with Aetna Case Managers, when processing transactions for members active in this Program (*)
- Supports the administration of the precertification process in compliance with various laws and regulations, URAQ and/or NCQA standards, where applicable, while adhering to Aetna policy and procedures (*)

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