Staff Nurse – Clinical Documentation Reviewer

About the role

The organization is seeking a Staff Nurse to ensure that clinical documentation supporting HMO claims, pre‑authorizations, and medical reviews is complete, accurate, and compliant. The role bridges nursing expertise with documentation quality, working closely with hospitals, clinics, and internal review teams.

Key responsibilities

• Review and validate clinical documents submitted for HMO claims, pre‑authorizations, and medical reviews.
• Confirm that medical records align with the member’s diagnosis, treatment, and procedures.
• Coordinate with hospitals, clinics, physicians, and other providers to obtain missing or incomplete documentation.
• Verify that submitted documents meet HMO guidelines, regulatory requirements, and internal policies.
• Support Claims, Utilization Management, and Medical Review teams by providing accurate documentation.
• Maintain confidentiality and security of member health information in line 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 the HMO information system.
• Assist in documentation audits, quality‑assurance initiatives, and process‑improvement activities.
• Prepare reports on documentation status, turnaround time, and compliance metrics.

Required profile

• Bachelor’s degree in Nursing, Medical Technology, Pharmacy, Physical Therapy, Healthcare Administration, or a related allied‑health field.
• Experience in an HMO, healthcare BPO, hospital, medical‑records department, 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.
• Excellent attention to detail, strong organizational abilities, and effective written and verbal communication.
• Ability to manage multiple tasks while meeting established turnaround times.

Required skills

• Microsoft Excel
• Microsoft Word
• Electronic Medical Records (EMR/EHR) systems