3850810-Executives

Nurse Level 1/2A Job Group Healthcare Family Name Healthcare Academy Job Title Nurse Level 1/2A Functional Title Associate Healthcare Academy 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 requiredEXL is the indispensable partner for leading businesses in data-led industries such as insurance, banking and financial services, healthcare, retail and logistics. We bring a unique combination of data, advanced analytics, digital technology and industry expertise to help our clients turn data into insights, streamline operations, improve customer experience, and transform their business. Our partnerships with clients are built on a foundation of collaboration - and we've been chosen as a partner by nine of the top ten leading US insurance companies, nine of the top 20 global banks, and six of the top ten US health care payers. We function as one team to make your goals our goals, whether that's unlocking the value of generative AI or embedding analytics into workflows that reduce risk or power your growth. Clients choose EXL as their transformation partner for many reasons. Our geographic diversity make talent all over the world instantly accessible. Digital accelerators enable unmatched speed-to-value, letting you realize results fast. It's our people that truly set us apart, though, including the 1,500 data scientists we have dedicated to our generative AI practice. And our more than twenty years of experience in delivering business services, garnering stellar client references, and maintaining a solid balance sheet are reassuring to our C-suite clients. Find out for yourself why clients, employees, and analysts think we're some of the best in the business. Contact us to see how we can help you achieve your goals.