Clinical Program Nurse II

Crawco; Asia; On-site; PEN 15,000 - 24,000; Full time

Job summary

Crawco is seeking a Registered Nurse to review medical information and determine medical necessity for treatments, in line with SOPs and Broadspire policies.

The role requires a Philippine RN license in good standing, at least one year of clinical experience, and proficiency with medical bill review processes. Candidates should be detail-oriented, able to multi-task, and maintain confidentiality while collaborating with physicians and internal stakeholders.

Qualifications

• Bachelor's degree in Nursing is required.
• Active and in good standing Philippine RN license.
• Minimum of one year clinical experience or prior experience in medical bill review or claim/case review.
• Proficient in word processing software applications.
• Analytical skills to perform basic bill review per SOP.
• Maintains professionalism and confidentiality.
• Ability to multi-task, prioritize and manage time effectively.
• Strong interpersonal skills to work independently and in a team.
• Must complete continuing education requirements mandated by the Professional Regulation Commission.
• Must complete courses outlined by Crawford Educational Services.

Responsibilities

• Review medical information to determine medical necessity and appropriateness according to standards.
• Evaluate medical information and apply established criteria to facilitate utilization review.
• Collaborate with peer physicians to facilitate case resolution.
• Document pertinent information to support utilization management determinations.
• Adhere to SOPs and turnaround times for review processes.
• Communicate policy knowledge to internal/external customers as needed.
• Plan and organize caseload to meet requirements.
• Refer matters beyond authority to immediate superior.
• Protect confidentiality in all communications.

Skills

Analytical skills

Multitasking

Interpersonal skills

Attention to detail

Professionalism

Education

Bachelor's degree in Nursing

Tools

Word processing

Job description

Job Description

Responsible for reviewing medical information to determine if requested treatment is medically necessary and appropriate according to the given standards.

Responsibilities

• Evaluation of Medical Information
  • Analyzes medical information and applies established criterion to facilitate the utilization review process.
  • Collaborates objectively with peer physicians to facilitate case resolution.
  • Utilizes appropriate resources to perform utilization review process.
  • Documents pertinent information in internal and external communications to support utilization management determinations and case resolutions.
  • Adheres to the given standard operating procedures (SOP) and turnaround time to complete the review process.
  • Demonstrates knowledge and understanding of Broadspire medical department policies and procedures and ability to communicate same with internal/ external customers as necessary.
• Business Process Support
  • Plans and organizes individual caseload to meet requirements.
  • Communicates effectively with persons involved in the review process as needed.
  • Refers matters beyond limits of authority and expertise to immediate superior for direction.
  • Upholds the Crawford Code of Conduct by protecting the confidentiality of information.
  • Performs other related tasks as required or needed.
  • Demonstrates knowledge and understanding of Broadspire medical department policies and procedures and ability to communicate same with internal/ external customers as necessary.

Qualifications

• Bachelor's degree in Nursing.
• Must have an active and in good standing without restriction Philippine RN license.
• Minimum of one (1) year diverse clinical experience or prior experience in medical bill review or claim/case review.
• Proficient in word processing software applications.
• Analytical skills - Ability to perform basic bill review according to standard operating procedures (SOP).
• Maintains high degree of professionalism and confidentiality.
• Ability to multi-task, prioritize and manage time effectively.
• Interpersonal skills - Able to work independently and as a team member.
• Keen attention to details.
• Must complete continuing education requirements mandated the Professional Regulation Commission.
• Must complete courses as outlined by Crawford Educational Services.