Staff Nurse

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 escalate complex cases to the appropriate clinical or medical management team. - Maintain organized electronic records and update documentation in the HMO information system. - Assist in documentation audits, quality assurance initiatives, and process improvement activities. - Prepare reports related to documentation status, turnaround time, and compliance metrics. Qualifications: - Bachelor's degree in Nursing, Medical Technology, Pharmacy, Physical Therapy, Healthcare Administration, or any allied health-related course. - Experience in an HMO, healthcare BPO, hospital, medical records, claims processing, or utilization management is preferred. - Knowledge of medical terminology, clinical documentation, and healthcare processes. - Familiarity with Electronic Medical Records (EMR/EHR) systems is an advantage. - Understanding of HMO operations, medical claims, and healthcare regulations is preferred. - Proficient in Microsoft Office applications, particularly Excel and Word. - Excellent attention to detail and organizational skills. - Strong written and verbal communication skills. - Ability to manage multiple tasks while meeting established turnaround times.