IRN - Clinical Services - Belgaum - Han Digital Solution

    Han Digital Solution
    Han Digital Solution Belgaum

    3 days ago

    Full time Healthcare
    Description

    Roles and Responsibilities

    • Perform intake of calls from members and providers via telephone, fax, and EDI regarding healthcare services
    • Utilize eTUMS and other Aetna systems to build, research, and update member information
    • Screen service requests and route cases appropriately to medical services staff
    • Approve services that do not require medical review in accordance with benefit plans
    • Conduct non-medical research including eligibility verification, coordination of benefits, and benefits validation
    • Maintain accurate, complete, and compliant documentation meeting risk management, regulatory, and accreditation standards
    • Support the precertification and utilization review process in compliance with laws, regulations, URAQ, and NCQA standards
    • Review and evaluate clinical documentation using clinical criteria, policies, and benefit determinations
    • Coordinate with internal and external clinicians, providers, and vendors to resolve clinical cases
    • Communicate effectively with case managers, healthcare teams, members, and external stakeholders
    • Protect confidentiality of member information and adhere strictly to organizational policies
    • Identify, report, and escalate quality of care issues, audit findings, and clinical concerns as required
    • Apply regulatory and accreditation standards consistently to ensure accurate and timely case processing

    Job Requirements

    • Active and valid nursing license
    • Bachelor of Science in Nursing (B.Sc Nursing); GNM qualification not eligible
    • 2 to 4 years of bedside clinical experience
    • Strong understanding of clinical documentation, utilization review, and care management processes
    • Familiarity with medical terminology and healthcare benefit structures
    • Proficiency in navigating multiple computer systems and applications
    • Strong customer service orientation and attention to detail
    • Effective verbal, written, and telephonic communication skills
    • Ability to multitask, prioritize, and adapt in a fast-paced environment
    • Willingness to work from office in a sedentary, office-based role
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