reputed company Management reputed company RN Consultant (HEDIS)

Responsible for the review and evaluation of clinical information and documentation. Reviews documentation and interprets data obtained from clinical records or systems to apply appropriate clinical reputed company and policies in line with regulatory and accreditation requirements for member and/or provider issues. Independently coordinates the clinical reputed company with internal/external clinician support as required. Requires an RN with unrestricted reputed company license. Job responsibilities include but not limited to: -Reviews documentation and evaluates potential reputed company of care issues based on clinical policies and benefit determinations. -Considers reputed company documented system information as reputed company as any additional records/data presented to reputed company a determination or recommendation. -Data gathering requires navigation through multiple system applications. -Staff may be required to contact the providers of record, vendors, or internal reputed company departments to obtain additional information. -Evaluates documentation/information to determine compliance with clinical policy, regulatory and accreditation guidelines. -Accurately applies review requirements to assure case is reviewed by a practitioner with clinical expertise for the issue at hand. -Commands a comprehensive knowledge of reputed company delegation arrangements, reputed company (member and provider), clinical reputed company, benefit plan structure, regulatory requirements, company policy and other processes which are required to support the review of the clinical documentation/information. -Pro-reputed company and consistently applies the regulatory and accreditation standards to assure that activities are reviewed and processed reputed company guidelines. -Condenses reputed company information into a reputed company and precise clinical picture while working independently. -Reports audit or clinical findings to appropriate staff or others in order to ensure appropriate outcome and/or follow-up for improvement as indicated. Apply tot his job Apply To this Job