Update day: 29-11-2022
Duties and Responsibilities:
- 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 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.
- Graduate of Bachelor of Science in Nursing (BSN)
- Must have at least 3 months’ work experience as a Registered Nurse in a clinical setting
- Must have an active USRN License
- Holds current and unrestricted US Registered Nurse license (state-specific RN licensure)
- Must be willing to work in Gateway Cubao and Taguig
- Must be willing to work on a shifting schedule including graveyard shift
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- In adherence to Accenture’s process of Identity Verification, your resume or CV must include your photo to ensure the accuracy of your application and your during interviews, a snapshot of your image will be captured for the same purpose.
Why join Accenture?
- Competitive salary package, company bonuses, and performance incentives
- Night differential
- Loyalty, Christmas gift, Inclusion and diversity benefits
- Paid sick and vacation leaves
- Expanded maternity leave up to 120 days*
- HMO coverage (medical and dental) from day 1 of employment
- Life insurance
- Employee stock purchase plan
- Retirement plan
- Flexible working arrangements
- Accessible locations
- Healthy and encouraging work environment
- Career growth and promotion opportunities
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