Medical Claims Review Senior Analyst

Job Description

Job Summary: The Nurse Clinical Advisor works closely with Customer Service, Care Team, Nurse Case Managers and Medical advisors to optimize use of healthcare services for all costumers while also ensuring the quality of care provided. The Nurse Clinical Advisor maintains accountability for achieving cost containment outcomes and fulfils the obligations and responsibilities of the role to support in the clinical progression of the costumer journey. Responsibilities: Part of a clinical team that provides evidence based medical management services to customers with serious conditions worldwide. Review and evaluate medical records and claims to determine the appropriate level of care for clients. Provide clinical guidance and support to clients, healthcare providers, and insurance staff on medical conditions and treatment options. Collaborate with healthcare providers to assesses the appropriateness of level of care and assists with length of stay management and utilization of resources Monitor clients' medical conditions and progress, and make recommendations for adjustments to care plans as needed. Assist in fraud detection Communicate and coordinate with clients, healthcare providers, and insurance staff to ensure that clients receive appropriate and cost-effective care. Maintain up-to-date knowledge of medical trends and advancements, and apply this knowledge to the evaluation of client cases. Assist and support the team in cost containment, assist in projects and service delivery to meet goals. Provide education and training to insurance staff on medical conditions, treatment options, and best practices in clinical care. Ensure that clients receive care that is in accordance with company policies and procedures, and that medical costs are managed effectively. Requirements: Active nursing license in good standing. Bachelor's degree in Nursing. Minimum of 3 years of experience in nursing, with experience in case management or clinical advisory preferred. Knowledge of medical terminology and medical conditions. Excellent communication and interpersonal skills. English Read, Write and Speak Fluently. Other languages desirable (Spanish, French, Arabic, German or Italian) Ability to work independently and as part of a team. Ability to handle confidential and sensitive information with discretion.