Clinical Program Nurse II

Crawford & Company; Iloilo City; On-site; PHP 360,000 - 600,000; Full time

Job summary

Crawford & Company in the Philippines is seeking a nurse reviewer to evaluate medical information and determine medical necessity for prescribed treatments. You will collaborate with peer physicians, apply criteria, and support utilization management determinations.

The role requires an active Philippine RN license, at least one year of clinical or medical bill review experience, and strong analytical and communication skills.

Qualifications

• Bachelor's degree in Nursing is required.
• 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.
• Proficient in word processing software applications.
• Analytical skills - Ability to perform basic bill review according to 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 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.
• Evaluation of Medical Information: Collaborates objectively with peer physicians to facilitate case resolution.
• Evaluation of Medical Information: Utilizes appropriate resources to perform utilization review process.
• Evaluation of Medical Information: Documents pertinent information in internal and external communications to support utilization management determinations and case resolutions.
• Evaluation of Medical Information: Adheres to the given SOP and turnaround time to complete the review process.
• Evaluation of Medical Information: Demonstrates knowledge of Broadspire medical policies and procedures and communicates them with internal/external customers as necessary.
• Business Process Support: Plans and organizes individual caseload to meet requirements.
• Business Process Support: Communicates effectively with persons involved in the review process as needed.
• Business Process Support: Refers matters beyond limits of authority and expertise to immediate superior for direction.
• Business Process Support: Upholds Crawford Code of Conduct by protecting confidentiality of information.
• Business Process Support: Performs other related tasks as required or needed.
• Business Process Support: Demonstrates knowledge of Broadspire policies and communicates them as necessary.

Skills

Analytical skills

Time management

Interpersonal skills

Attention to detail

Education

Bachelor's degree in Nursing.

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.