Responsible for the review and evaluation of clinical information and documentation.
Reviews documentation and interprets data obtained from clinical records or systems to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and/or provider issues.
Independently coordinates the clinical resolution with internal/external clinician support as required.
Requires an RN with unrestricted active license
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 issueat hand.
Commands a comprehensive knowledge of complex delegation arrangements, contracts ,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.-Condenses complex information into a clear and precise clinical picture while working independently.
Reports audit or clinical findings to appropriate staff or others in order to ensure appropriate outcome and/or follow-up for improvement as indicated. #J-18808-Ljbffr
All Job Ads are subject to GrabJobs’s Terms of Service. We allow users to flag postings that may be in violation of those terms. Job Ads may also be flagged by GrabJobs moderation team. However, no moderation system is perfect, and flagging a posting does not ensure that it will be removed.
Be the first to receive the latest Others Full-Time Jobs in the US.
Setup your job alert:
By activating job alerts, I agree to GrabJobs Terms & Privacy Policy. I can unsubscribe to job alerts anytime.
Skip
GrabJobs is the no1 job portal in the US, connecting you to thousands of jobs fast!
Find the best jobs in the US, apply in 1 click and get a job today!