Nurses (US Registered) Bangalore

Nurses (US Registered) Bangalore

2COMS Consulting Private Limited
1-5 years
Not Specified

Job Description

USRN:(US Registered Nurses)

Qualifications:


  • US registered nurse with 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(NClex Certified)

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.




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