Clinical Program Nurse II

Crawford-; Manila; Sur place; PHP 360 000 - 600 000; Plein temps

Résumé du poste

Crawford Educational Services in Manila, Philippines seeks a Nursing Utilization Review Specialist to review medical information for necessity and appropriateness. You will collaborate with physicians to resolve cases and document findings in accordance with SOPs and policy.

The role emphasizes confidentiality, time management, and effective communication across stakeholders. The ideal candidate holds a Philippines RN license, a Bachelor's in Nursing, and at least one year of clinical or medical

Qualifications

• Bachelor's degree in Nursing.
• Active Philippine RN license in good standing.
• Min. 1 year clinical experience or medical bill review.
• Proficient in word processing software.
• Strong analytical skills for bill review.
• Maintains professionalism and confidentiality.
• Able to multi-task, prioritize, and manage time.
• Excellent interpersonal and teamwork abilities.
• Completes continuing education requirements per PRC.
• Completes Crawford Educational Services courses.

Responsabilités

• Review medical information to determine medical necessity and appropriateness.
• Analyze information and apply criteria to assist utilization review.
• Collaborate with peer physicians for case resolution.
• Use resources to perform utilization review.
• Document pertinent information to support determinations and resolutions.
• Follow SOPs and turnaround times for reviews.
• Communicate policies to internal/external customers as needed.
• Plan and organize caseload to meet requirements.
• Communicate effectively with review process participants.
• Refer matters beyond authority to supervisor for direction.
• Protect confidentiality per Crawford Code of Conduct.
• Perform other related tasks as required.

Connaissances

Analytical skills

Word processing

Interpersonal skills

Attention to detail

Time management

Formation

Bachelor's degree in Nursing

Description du poste

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.