Registered Nurse - Insurance Claims Adjudication

requests, correspondence inquiries and image review

• Forward the cases to appropriate teams, post the in-scope activities have been completed as per SOP (Standard operating Procedure)
• Prep medical records for clinical review
• End to end processing and resolution of clinical claims and correspondence
• Understand/interpret medical terminology including clinical notes and reports
• Able to review medical policies and determine the appropriate claim processing or clinical review process decisions (pay, request additional records, refer for clinical review)
• Review and determine pricing for clinical claims in accordance with negotiated pricing agreements
• Adept knowledge of verifying member benefits, eligibility verification and medical necessity determination
• To apply clinical judgement in lines of applicable guidelines while they provide post service Medical Necessity Determination (MND) reviews for Claim Policy business area led by reputed US Payer organization/s
• To work in collaboration with Medical Directors to deliver top quality medical necessity determination services to clients

Basic Qualifications

• High School Diploma or GED Equivalent
• At least 2 years of experience relating to the job description

Preferred Qualifications

• Fully Bilingual- English and Spanish- (All work performed will be in English)

• Current Puerto Rico Registered Nurse valid license and a valid Florida or any US state endorsement

• Intermediate to advanced knowledge in using MS Office and ability to learn and use various computer software

• Past experience in an office/clerical setting in the medical field

• Experience in any claim adjudication platform

• Certification in medical coding (CPT, ICD-10

• Exposure to Healthcare Claims products (Indemnity, PPO, POS/DA, EPO, HMO)

• Prefer knowledge of Workman's Compensation, Medicare, COB, no fault

• Prior claims experience in medical coding, case management, cost containment review, medical claim management will be preferred

• Exposure to anti-fraud initiatives in clinical area

• Awareness of clinical practice guidelines used by health plans to develop medical policy

• Possess eye for details

• Knowledge of Microsoft Office Products

• Team Player, Analytical, Written and Verbal Communication Skills, Interpersonal Skills and Positive Attitude

Note : Applicants for employment in the U.S. must possess work authorization which does not require sponsorship by the employer for a visa (H1B or otherwise).

The job entails sitting as well as working at a computer for extended periods of time. Should be able to communicate by telephone, email or face to face.

Work Model:
This role is onsite 5 days per week in the office in Aguadilla.

Who We Are
Infosys BPM Limited, a wholly owned subsidiary of Infosys Limited (NYSE: INFY), provides end-to-end transformative business process management (BPM) services for its clients across the globe. The company's integrated IT and BPM solutions approach enables it to unlock business value across industries and service lines, and address business challenges for its clients. Utilizing innovative business excellence frameworks, ongoing productivity improvements, process reengineering , automation , and cutting-edge technology platforms, Infosys BPM enables its clients to achieve their cost reduction objectives, improve process efficiencies, enhance effectiveness, and deliver superior customer experience.

Infosys BPM has 45 delivery centers in 16 countries spread across 5 continents, with 56,541 employees from 107 nationalities, as of December, 2023.

The company has been consistently ranked among the leading BPM companies globally and has received over 60 awards and recognitions in the last 5 years, from key industry bodies and associations like the Outsourcing Center, SSON, and GSA, among others. Infosys BPM also has very robust people practices, as substantiated by the various HR-specific awards it has won over the years. The company has consistently been ranked among the top employers of choice, on the basis of its industry leading HR best practices. The company's senior leaders contribute widely to industry forums as BPM strategists.

EOE/Minority/Female/Veteran/Disabled/Sexual Orientation/Gender Identity/National Origin

Infosys BPM is an equal opportunity employer and all qualified applicants will receive consideration without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, protected veteran status, spouse of protected veteran, or disability.