Found Description
Key Responsibilities
- Review and validate clinical documents submitted in support of HMO claims, pre-authorizations, and medical reviews.
- Ensure medical records are complete, accurate, and consistent with the member's diagnosis, treatment, and procedures.
- Coordinate with hospitals, clinics, physicians, and healthcare providers to obtain missing or incomplete documentation.
- Verify that submitted clinical documents meet HMO guidelines, regulatory requirements, and internal policies.
- Support Claims, Utilization Management, and Medical Review teams by providing complete and accurate documentation.
- Maintain confidentiality and security of member health information in accordance with the Data Privacy Act and company policies.
- Identify documentation discrepancies and elevate complex cases to the appropriate clinical or medical management team.
- Maintain organized electronic records and update documentati...