Job Summary

• We are seeking a detail-oriented and clinically experienced Registered Nurse to join our team as Nurse Administrator.
• This role will be responsible for conducting clinical and quality audits of HMO claims batches, managing inpatient cases, and coordinating with healthcare teams to ensure compliance with regulatory requirements and health insurance standards.

Key Responsibilities

• Conduct thorough clinical and quality audits of claims batches prior to submission to health insurance companies, ensuring compliance with regulatory requirements and company standards.
• Collect and collate supporting medical information and reports from medical teams on a case-to-case basis, maintaining accurate and up-to-date records.
• Manage inpatient cases, providing weekly reports on progress and outcomes based on established criteria.
• Submit clinical updates to health insurance companies for inpatient cases, adhering to specific requirements and timelines.
• Review and record rejection reports, implementing corrective measures to improve claim approval rates and reduce denials.
• Provide clinical expertise and support to the HMO team, conducting reviews and consultations as needed.
• Preparing reports and other duties assigned.

Requirements

• Registered Nurse (RN) / Registered Midwife (RM) or Bachelor’s Degree in Nursing.
• Minimum of 2 (two) years of experience in clinical review, case management, or a related field.
• Current nursing license.
• Strong understanding of health insurance policies and procedures.
• Excellent communication and analytical skills.
• Ability to work effectively in a team environment.

Preferred Qualifications:

• Experience working with HMOs or health insurance companies.
• Knowledge of medical coding and billing procedures.