Clinical Program Nurse I

Offres d’emploi Crawford - Mondiales; Manila; On-site; PHP 420,000 - 640,000; Full time

Job summary

Crawford - Mondiales in the Philippines is seeking a Registered Nurse with experience in medical bill review to audit inpatient and surgical bills, ensure accuracy, and support reimbursement decisions. The role requires strong analytical skills, adherence to SOPs, and collaboration with physicians and legal teams as needed.

The candidate should hold an active Philippine RN license and have at least one year of relevant clinical or bill-review experience, with proficiency in standard office

Qualifications

• Bachelor's degree in Nursing and active Philippine RN license required.
• 1 year of diverse clinical experience or medical bill review experience preferred.
• Proficiency in word processing software and basic data handling required.
• Strong analytical skills and ability to follow SOPs for bill review.

Responsibilities

• Audit inpatient and/or surgical bills to ensure accuracy and adherence to SOPs.
• Review and process bills within required turnaround times.
• Clarify billing discrepancies and recommend reimbursement.
• Document notes in the system to support reimbursement decisions.
• Conduct bill reconsiderations when requested to ensure accuracy of original determinations.
• Collaborate with physicians and other stakeholders to determine reimbursement.
• Communicate policy procedures to internal and external customers as needed.
• Assist in related billing process issues and liaise with attorneys when required.

Skills

Clinical experience

Analytical skills

Multitasking

Time management

Interpersonal skills

Attention to detail

Professionalism

Education

Bachelor's degree in Nursing

Philippine RN license

Continuing education (PRC)

Crawford Educational Services courses

Tools

Word processing software

Job description

• Process Code BSI004.001 PRS Coordinators Admin (Peer Claims File Review)
• Equipment Field Dell Wyse 5470 Mobile Thin Client Package with 1 monitor, keyboard, mouse, cables
• Work Station Assignment 25-065
• Nurse License PH Registered Nurse

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.
  • Collaborates objectively with peer physicians to facilitate determination of reimbursement.
  • 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
  • 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.
• 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.