Usrn - Nclex, Clinical Review

**Job Information**:
Industry

**Non-IT Lateral**
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Province

**Karnataka**
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City

**Bangalore North**
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Postal Code

**560001**
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Country

**India**

**Skill required**:
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**Healthcare Management - Clinical Care Delivery Operations**

**Designation**:
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**Senior Analyst**

**Job Location**:
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**Bengaluru**

**Qualifications**:
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**BSc. Nursing**

**Years of Experience**:
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**5 to 8 years**

**What would you do?**
- Complete review of pended post-service claims for appropriateness of treatment setting,
- contractual reviews, or medical necessity.
- Determine contract and benefit eligibility.
- Follow and comply with all applicable regulatory and accreditation requirements.
- Utilize applicable client-specific medical policies, clinical guidelines, and/or client
- specific criteria
- sets (e.g., Milliman or InterQual) when performing clinical review.
- Request additional clinical information as needed per client guidelines.
- Route cases to the Client's physician reviewer for a determination when a service or admission
- does not meet medical necessity, place of service, or benefit criteria.
- Maintain accurate and complete clinical and administrative case documentation using client
- approved templates.
- Prepare detailed case summaries for physician review.
- Consult with Radiant clinical leaders and/or U.S. licensed client physician reviewers as needed throughout the clinical claim review process.
- Responsibilities exclude making adverse determinations or providing medical advice/opinion on
- treatment or services.
- Support accreditation by knowing, understanding, correctly interpreting, and accurately applying
- accrediting and regulatory requirements and standards.
- Data entry into client systems and route as appropriate.
- Uses available resources to understand contractual and regulatory compliance requirements and
- reports suspected compliance issues on the day of discovery to a Team Lead, Manager, and/or the
- Compliance Department.
- Responsible for reporting known or suspected data disclosures on the day of discovery to a Team
- Lead or Manager.

**What are we looking for?**
- Holds current and unrestricted US Registered Nurse license.
- Holds state specific RN licensure as required.
- Excellent written and verbal communication skills in English.
- Proficiency in basic computer knowledge with the ability to learn additional computer programs.
- A minimum of three (3) months of prior working experience as a Registered Nurse in a clinical
- setting, preferred. o Three months is equivalent to 480 hours of working experience as an RN. o
- Working experience as a Registered Nurse means holding an active RN license and providing direct
- patient care o Clinical setting includes inpatient hospital, outpatient hospital or clinic.
- and member benefits, preferred.
- Strong analytical skills, preferred.
- Strong customer service focus. o Ability to empathize, preferred. o Prioritizing customer needs,
- preferred. o Listening, patience & action oriented, preferred o Good understanding of phone
- etiquette, preferred.
- Knowledge of ICD-9 and ICD-10 and CPT codes, preferred.
- Experience in medical or insurance field, preferred.
- Claim reviews/audit experience, preferred.
- Experience in United States medical or insurance field, preferred.

**Roles and Responsibilities**
- In this role you are required to do analysis and solving of increasingly complex problems
- Your day to day interactions are with peers within company
- You are likely to have some interaction with clients and/or management
- You will be given mínimal instruction on daily work/tasks and a moderate level of instruction on new
- assignments
- Decisions that are made by you impact your own work and may impact the work of others
- In this role you would be an individual contributor and/or oversee a small work effort and/or team
- Please note that this role may require you to work in rotational shifts