Clinical Program Nurse II

Crawford & Company; Manila; On-site; PHP 300,000 - 550,000; Full time

Job summary

Crawford & Company in Manila is seeking a detail-oriented RN reviewer to assess medical information for medical necessity and appropriateness according to established standards.

The role focuses on evaluation of medical information, collaboration with peers, and adherence to SOPs, with emphasis on confidentiality and professional communication with internal and external customers. A Philippine RN license and at least one year of clinical experience are required.

Qualifications

• Bachelor's degree in Nursing.
• Active Philippine RN license in good standing.
• Minimum 1 year clinical experience or medical bill review/case review experience.
• Strong communication skills.
• Proficient in word processing software.
• Analytical skills for basic bill review per SOP.
• Maintains professionalism and confidentiality.
• Ability to multi-task, prioritize and manage time.

Responsibilities

• Evaluate medical information and apply criteria to utilization review.
• Collaborate with peer physicians to resolve cases.
• Document pertinent information in communications for determinations.
• Adhere to SOPs and turnaround times in reviews.
• Communicate policies to internal/external customers as needed.
• Protect confidentiality per Crawford Code of Conduct.

Skills

Good communication

Analytical skills

Interpersonal skills

Multi-tasking

Attention to detail

Time management

Education

Bachelor's degree in Nursing

Tools

Microsoft Word

Job description

Job 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.