Clinical Program Nurse II

Crawford & Company; Iloilo City; On-site; PHP 600,000 - 800,000; Full time

Job summary

A healthcare services provider in Iloilo City is seeking a qualified nursing professional to review medical information for treatment necessity. Responsibilities include analyzing cases, collaborating with physicians, and adhering to established guidelines. Candidates must hold a valid Philippine RN license and have at least one year of clinical experience. Strong communication and analytical skills are essential, alongside a commitment to professionalism and detail.

Qualifications

• 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.

Responsibilities

• Analyzes medical information to facilitate the utilization review process.
• Collaborates with peer physicians to facilitate case resolution.
• Documents information to support utilization management determinations.

Skills

Good communication skills

Analytical skills

Interpersonal skills

Keen attention to details

Education

Bachelor's degree in Nursing

Philippine RN license

Job description

Overview

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 by the Professional Regulation Commission.
• Must complete courses as outlined by Crawford Educational Services.