IRN - Clinical Services

Roles and Responsibilities

• Perform intake of calls from members and providers via telephone, fax, and EDI regarding healthcare services
• Utilize eTUMS and other Aetna systems to build, research, and update member information
• Screen service requests and route cases appropriately to medical services staff
• Approve services that do not require medical review in accordance with benefit plans
• Conduct non-medical research including eligibility verification, coordination of benefits, and benefits validation
• Maintain accurate, complete, and compliant documentation meeting risk management, regulatory, and accreditation standards
• Support the precertification and utilization review process in compliance with laws, regulations, URAQ, and NCQA standards
• Review and evaluate clinical documentation using clinical criteria, policies, and benefit determinations
• Coordinate with internal and external clinicians, providers, and vendors to resolve clinical cases
• Communicate effectively with case managers, healthcare teams, members, and external stakeholders
• Protect confidentiality of member information and adhere strictly to organizational policies
• Identify, report, and escalate quality of care issues, audit findings, and clinical concerns as required
• Apply regulatory and accreditation standards consistently to ensure accurate and timely case processing

Job Requirements

• Active and valid nursing license
• Bachelor of Science in Nursing (B.Sc Nursing); GNM qualification not eligible
• 2 to 4 years of bedside clinical experience
• Strong understanding of clinical documentation, utilization review, and care management processes
• Familiarity with medical terminology and healthcare benefit structures
• Proficiency in navigating multiple computer systems and applications
• Strong customer service orientation and attention to detail
• Effective verbal, written, and telephonic communication skills
• Ability to multitask, prioritize, and adapt in a fast-paced environment
• Willingness to work from office in a sedentary, office-based role