Executives

Nurse Level 1/2A

Job Group Healthcare

Family Name Complaints, Grievance and Appeals

Job Title Nurse Level 1/2A

Functional Title Coding Reconsideration – Nurse Consultant

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 3 rd 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