Clinical Program Nurse II

Crawford & Company; Iloilo; On-site; PHP 335,000 - 558,000; Full time

Job summary

Crawford & Company Philippines seeks a licensed nurse to review medical information to determine if proposed treatment is medically necessary and appropriate according to established standards.

The role involves evaluating medical data, collaborating with physicians, and performing utilization reviews while maintaining confidentiality and adhering to SOPs and Crawford policies.

Qualifications

• Bachelor's degree in Nursing.
• Active and in good standing Philippine RN license.
• Minimum of one 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.
• 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 by the Professional Regulation Commission.
• Must complete courses as outlined by Crawford Educational Services.

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 SOP and turnaround time to complete the review process.
• Demonstrates knowledge of Broadspire medical department policies and procedures and communicates them with internal/external customers as necessary.
• 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 Crawford Code of Conduct by protecting confidentiality of information.
• Performs other related tasks as required or needed.
• Demonstrates knowledge and understanding of Broadspire medical department policies and procedures and communicates them with internal/external customers as necessary.

Skills

Good communication

Analytical skills

Interpersonal skills

Attention to detail

Time management

Teamwork

Confidentiality

Multi-tasking

Independent worker

Education

Bachelor's degree in Nursing

Tools

Microsoft Word

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.
• 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.