IRN - Clinical Services-1

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, p...