Clinical Program Nurse II

Offres d’emploi Crawford - Mondiales; Iloilo; On-site; PHP 446,000 - 670,000; Full time

Job summary

Crawford - Mondiales in the Philippines seeks a Registered Nurse to perform utilization review by evaluating medical information and applying criteria for treatment necessity. You will collaborate with physicians, document communications, and ensure adherence to SOPs while maintaining strict confidentiality.

The role requires a bachelor’s in nursing, an active Philippine RN license, and at least one year of relevant experience.

Qualifications

• Bachelor's degree in Nursing.
• Active Philippine RN license in good standing.
• Minimum 1 year clinical experience or prior medical bill/claims review experience.
• Proficient in word processing software.
• Analytical skills to perform bill review per SOP.
• Maintains high professionalism and confidentiality.
• Able to multi-task, prioritize, and manage time effectively.
• Strong interpersonal skills for team collaboration.
• Must comply with PRC continuing education requirements.
• Must complete Crawford Education Services courses.

Responsibilities

• Review medical information to determine necessity and appropriateness of requested treatment.
• Analyze information and apply established criteria to support utilization review.
• Collaborate with peer physicians to resolve cases.
• Use resources to perform utilization review tasks.
• Document pertinent information in communications to support determinations.
• Adhere to SOPs and turnaround times for reviews.
• Communicate Crawford policies to internal and external customers as needed.

Skills

Analytical skills

Attention to detail

Interpersonal skills

Time management

Professionalism

Confidentiality

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.