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Pre-Certification Nurses LPN
From:
Company: Bravo Health (see all of this employer's jobs)
Phone: 4432244757
Fax: 1234567890
 Apply by eMail:do_not_reply@invalidemail.com
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Job Reference ID:
5112592
Category:
Engineering
Duration:
Fulltime, Permanent
City, ST:
Philadelphia, Pennsylvania
Country:
United States |
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Description:
POSITION SUMMARY:
The PreCertification Nurse is responsible for supporting the Medical Director and Director of Health Services. Responsibilities include assuring above standard health care services are available to Bravo members in an appropriate cost-effective manner and delivery of those services emphasize preventive care and promote healthy outcomes.
ESSENTIAL DUTIES AND RESPONSIBILITIES include the following:
§ Responsibilities include collecting, analyzing, and evaluating clinical documentation received using Interqual Criteria to determine appropriateness of clinical decisions; Meet/exceed service level goals (e.g., Grade of Service, Average Handle Time, Average Speed to Answer, Abandonment Rate);
§ Documentation of clear, concise and appropriate clinical documentation;
§ Adherence to regulatory and departmental timeframes for review of requests received;
§ Ability to communicate effectively with the Medical Director clinical information received that may lead to adverse clinical determinations;
§ Meets regularly with the Medical Director for claims review, research, adjudication and identification of utilization trends and generation of monthly written reports;
§ Process approval and adverse clinical determination correspondence for members, contracted and non-contracted providers;
§ Activates and maintains tracking systems of approval and adverse clinical determinations;
§ Accurate completing of data entry into the Health Services software systems;
§ Verification of member and provider eligibility;
§ Providing excellent customer service when communicating with internal and external customers;
§ Initiate the letter of agreement process, working with Network Management to ensure Service Level Agreements are completed in a timely manner when applicable
§ Completion of clinical reviews for non authorized medical claims;
Apply by eMail:do_not_reply@invalidemail.com
Job Created:
Wed Oct 21 2009 06:43:30 AM
Last Modified: Sat Nov 21 2009 06:56:00 AM
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