Clinical Program Nurse I

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

Job summary

Crawford & Company in the Philippines is seeking a Medical Bill Review Auditor who will process inpatient and outpatient bills according to SOPs and timelines, with a focus on accuracy and reimbursement determination.

The role requires a Bachelor’s in Nursing and an active Philippine RN license, plus at least 1 year of clinical or medical bill review experience, strong communication, and the ability to work independently within a team.

Qualifications

• Bachelor's degree in Nursing required.
• Active Philippine RN license required.
• Minimum 1 year clinical experience or prior experience in medical bill review or claim/case review.
• Good communication skills.
• Proficient in word processing software applications.

Responsibilities

• Audits inpatient and/or surgical bills following SOPs and turnaround times.
• Performs bill review and uses appropriate resources.
• Clarifies billing discrepancies to analyze and recommend reimbursement.
• Documents information in system bill notes to support determination.
• Performs reconsideration of bills as requested to ensure proper processing.
• Collaborates with peer physicians to determine reimbursement.
• Understands Broadspire policies and communicates them to internal/external customers.

Skills

Communication skills

Analytical skills

Attention to detail

Multitasking

Teamwork

Discretion/Professionalism

Education

Bachelor's degree in Nursing

Philippine RN license

Tools

MS Word

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.
  • 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.
• 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.