Associate - Nurse

Associate - Nurse (BSc)

Basic Function

Facilitate the delivery of applicable benefits that are reasonably and appropriately billed, which in turn promotes cost effective outcomes for all the members who require our services.

Essential Functions

Responsible for the review and evaluation of the services being appealed based on the available information and medical policy

• Reviews documentation and evaluates whether the services performed were appropriate based on clinical policies and guidelines
• 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.
• Commands a comprehensive knowledge of complex delegation arrangements, contracts (member and provider), 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 apply the regulatory and accreditation standards to ensure that activities are reviewed and processed within guidelines.
• Condenses complex information into a clear and precise clinical picture
• Independently prepares a clinical summary for medical doctor review and provides a recommendation whenever necessary
• Work requires the ability to perform close inspection of handwritten and computer-generated documents as well as a PC monitor.

Education Requirements

• India Registered Nurse with an active license (BSc Nurse)

Work Experience Requirements

• 2 years of Clinical Experience
• Practical experience in the nursing field: hospital, industrial, community, outpatient and clinical