19365 HEDIS Consultant
Location: Philadelphia Pennsylvania
Description: CCSI, Inc is at present looking to employ 19365 HEDIS Consultant right now, this job will be placed in Pennsylvania. Further informations about this job opportunity kindly read the description below. Location: Philadelphia, PA
Length: 3 Months
If interested, please send resumes to Joanna@ccsiinc.com
Description:
Responsible for the review and res! olution of clinical documentation, clinical complaints and appeals. Reviews documentation and interprets data obtained from clinical records to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and provider issues. Independently coordinates the clinical resolution with internal/external clinician support as required. Requires an RN with unrestricted active license.
Fundamental Components & Physical Requirements include but are not limited to:
Reviews complaint/appeal requests of all clinical and benefit documentation. Considers all previous information as well as any additional records/data presented to render a recommendation/review. Data gathering requires navigation through multiple system applications. Contacts the provider of record, vendors or internalcompany departments to obtain additional information. Accurately applies review requirements to assure case is reviewed by a practioner with clinic! al expertise for the appeal issue at hand (e.g. Specialty Matc! h Review (SMR). Commands a comprehensive knowledge of complex delegation arrangements, coding logic, contracts (member and provider), clinical criteria, benefit plan structure, regulatory requirements and ERO eligibility which are required to support the appeals review. Pro-actively and consistently applies the regulatory and accreditation standards to assure that appeals and ERO requests are processed within requirements. Condenses complex information into a clear and precise clinical picture while working independently. Coordinates appeal process, in collaboration with members and their authorized representatives, providers, regulators, internal/external consultants and participants (e.g. fair hearing, state mandated reviews, chairs appeal panel hearings) in compliance with state regulation and benefit plan designs. Reports findings to team leader/supervisors, responds to rebuttal issues and makes recommendations for improvement as indicated. Exhibits the following Appeal! s Nurse Consultant Behaviors Background/Experience Desired Managed Care experience preferred 3-5 years of clinical experience required Education and Certification Requirements RN with current unrestricted state licensure.
Additional Information:
Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding Effective communication skills, both verbal and written. Ability to multitask, prioritize and effectively adapt to a fast paced changing environment Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer. Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor. Typical office working environment with productivity and quality expectations
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If you were eligible to this job, please email us your resume, with salary req! uirements and a resume to CCSI, Inc.
If you interested on this job just click on the Apply button, you will be redirected to the official website
This job starts available on: Sat, 31 Aug 2013 06:23:57 GMT
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