MCS Puerto Rico
GENERAL DESCRIPTION
Evaluates utilization in clinical records and hospital facilities concurrently and retrospectively. Identifies and refers to other clinical departments (Case management, condition management, among others) for the management of treatment alternatives. Makes efforts to receive advice in difficult situations in cases under evaluation.
ESSENTIAL FUNCTIONS
Visits hospitals and health facilities to assess utilization concurrently or retrospectively in clinical records using clinical guidelines and procedures established by the Clinical Affairs department.
Performs daily audit entries and verifies closed cases in electronic systems.
Evaluates the justification of the services provided and notifies of and refers to management of any irregular utilization patterns to ensure the services' quality.
Identifies and reports cases with potential risks to other clinical departments for managing alternative treatment alternatives, case management in extended stays, or readmissions following established guidelines and procedures.
Identifies, intervenes, and suggests care alternatives to the provider to coordinate the patient discharge plan.
Participates in special projects assigned to the department and as required.
Compliance with the operational standards established by the Clinical Affairs department and CMS guidelines.
Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our industry to maintain appropriate business and employment practices.
May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document.
MINIMUM QUALIFICATIONS Education and Experience:
Bachelor’s Degree in Nursing. At least one (1) year of experience working in a clinical area and reviewing hospital utilization, preferably in the Health Insurance Industry.
Certifications / Licenses:
A valid Nursing and Registration license is required.
Other:
A Driver’s License valid in the Commonwealth of Puerto Rico is required.
Languages:
Spanish – Advanced (comprehensive, writing and verbal); English – Advanced (comprehensive, writing and verbal).
EEO Statement "Somos un patrono con igualdad de oportunidad en el empleo y tomamos Acción Afirmativa para reclutar a Mujeres, Minorías, Veteranos Protegidos y Personas con Impedimento"
Seniority Level Entry level
Employment type Full-time
Job function Health Care Provider
Industry Insurance
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ESSENTIAL FUNCTIONS
Visits hospitals and health facilities to assess utilization concurrently or retrospectively in clinical records using clinical guidelines and procedures established by the Clinical Affairs department.
Performs daily audit entries and verifies closed cases in electronic systems.
Evaluates the justification of the services provided and notifies of and refers to management of any irregular utilization patterns to ensure the services' quality.
Identifies and reports cases with potential risks to other clinical departments for managing alternative treatment alternatives, case management in extended stays, or readmissions following established guidelines and procedures.
Identifies, intervenes, and suggests care alternatives to the provider to coordinate the patient discharge plan.
Participates in special projects assigned to the department and as required.
Compliance with the operational standards established by the Clinical Affairs department and CMS guidelines.
Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our industry to maintain appropriate business and employment practices.
May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document.
MINIMUM QUALIFICATIONS Education and Experience:
Bachelor’s Degree in Nursing. At least one (1) year of experience working in a clinical area and reviewing hospital utilization, preferably in the Health Insurance Industry.
Certifications / Licenses:
A valid Nursing and Registration license is required.
Other:
A Driver’s License valid in the Commonwealth of Puerto Rico is required.
Languages:
Spanish – Advanced (comprehensive, writing and verbal); English – Advanced (comprehensive, writing and verbal).
EEO Statement "Somos un patrono con igualdad de oportunidad en el empleo y tomamos Acción Afirmativa para reclutar a Mujeres, Minorías, Veteranos Protegidos y Personas con Impedimento"
Seniority Level Entry level
Employment type Full-time
Job function Health Care Provider
Industry Insurance
#J-18808-Ljbffr