Clinical Program Nurse II

Crawco; Iloilo; Vor Ort; PHP 360.000 - 480.000; Vollzeit

Zusammenfassung

Crawco is seeking a qualified Registered Nurse to review medical information for medical necessity and appropriateness. You will evaluate medical data, apply utilization criteria, and collaborate with peers to resolve cases while maintaining confidentiality and SOP adherence.

The role requires an active Philippine RN license, a Bachelor’s in Nursing, and at least one year of relevant clinical or medical review experience.

Qualifikationen

• Bachelor's degree in Nursing is required.
• Active Philippine RN license in good standing is required.
• At least 1 year of diverse clinical experience or prior medical bill review/claim review experience.
• Proficiency in word processing software and strong analytical skills.
• Maintains professionalism and confidentiality; capable of multitasking.

Aufgaben

• Review medical information to determine medical necessity and appropriateness.
• Analyze information and apply criteria to support utilization review.
• Collaborate with peer physicians to facilitate case resolution.
• Document pertinent information in communications to support determinations.
• Follow SOPs and turnaround times for the review process.
• Uphold policies and communicate with internal/external customers as necessary.
• Plan and organize caseload, and refer matters beyond authority when needed.

Kenntnisse

Analytical skills

Interpersonal skills

Time management

Multitasking

Attention to detail

Ausbildung

Philippine RN license

Bachelor's degree in Nursing

Tools

Microsoft Word

Jobbeschreibung

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.