Clinical Program Nurse I

Crawford & Company; Iloilo; On-site; PHP 300,000 - 540,000; Full time

Job summary

Crawford & Company is seeking a Nursing professional in Iloilo to audit inpatient and/or surgical bills for medical bill review and process improvement.

The role requires an active Philippine RN license and a Bachelor’s degree in Nursing, plus at least one year of clinical experience or prior exposure to medical bill review. Strong communication, confidentiality, and analytical skills are essential for success, with adherence to SOPs and company guidelines.

Qualifications

• Bachelor's degree in Nursing.
• Active Philippine RN license in good standing.
• Minimum of one year clinical experience or prior medical bill review experience.
• Good communication skills.
• Proficient in word processing software.
• Analytical skills to perform basic bill review according to SOP.
• Maintains professionalism and confidentiality.
• Ability to multi-task, prioritize and manage time effectively.
• Interpersonal skills to work independently and as a team member.
• Keen attention to details.
• Must complete continuing education requirements mandated by the Professional Regulation Commission.
• Must complete courses as outlined by Crawford Educational Services.

Responsibilities

• Audit inpatient and/or surgical bills by adhering to SOP and turnaround time.
• Perform bill review using appropriate resources.
• Clarify billing discrepancies to analyze and recommend reimbursement.
• Document pertinent information in system bill notes to support reimbursement determination.
• Perform reconsideration of bills upon request to ensure appropriate processing.
• Provide business process support to associates and other departments with billing issues and fee schedules.
• Inform process owners regarding issues related to calculation of reimbursement.
• Communicate with case management process participants as needed.
• Liaise with company attorneys to assist in litigated claims.
• Refer matters beyond limits of authority to immediate superior.
• Uphold Crawford Code of Conduct and confidentiality.
• Perform other related tasks as required.
• Demonstrate knowledge of Broadspire medical department policies and communicate them to internal/external customers.

Skills

Communication

Analytical

Multitasking

Interpersonal

Attention to detail

Confidentiality

Education

Bachelor's degree in Nursing

Philippine RN license

Tools

Word processing software

Job description

Job Description

Responsible for auditing in-patient and/or surgical bills to promote excellence in medical bill review and process improvement.

Responsibilities

• Medical Bill Review
• Processes inpatient and/or surgical bills by adhering to the given standard operating procedures (SOP) and turnaround time to complete the task.
• Performs bill review process by utilizing appropriate resources.
• Clarifies billing discrepancies to analyze and recommend appropriate reimbursement.
• Documents pertinent information in the system bill notes to support reimbursement determination.
• Performs reconsideration of bills, as per request, to ensure original bill processing determination is appropriate.
• Business Process Support
• Provides assistance to Business Process Associates and other concerned departments with regards to billing issues, inquiries on fee schedules and/or ground rules for a particular state.
• Inform appropriate process owner regarding issues related to calculation of reimbursement.
• Communicates effectively with persons involved in case management process as needed.
• Liaise with company attorneys to assist in possible litigated claims.
• 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.
• Good communication skills.
• 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.