Customer Service Rep- for Nurses ( clinical account) - QC

Sagility Philippines B.V. Branch Office; Quezon City; On-site; PHP 300,000 - 420,000; Full time

Job summary

A healthcare services company in Quezon City is seeking a professional to perform Utilization Management reviews. The role involves assessing clinical information against established criteria, maintaining compliance with regulations, and protecting members' health information. Candidates should ensure timely responses to inbound calls and participate in discussions with medical leadership. This position requires a strong understanding of healthcare compliance and member interaction.

Responsibilities

• Accesses the appropriate coverage criteria.
• Performs Utilization Management review in accordance to regulations.
• Maintains compliance with regulatory changes affecting Utilization Management.
• Reviews clinical information against established criteria.
• Documents review.
• Protects and secures members' Protected Health Information.
• Responds to inbound calls pertaining to reviews.
• Participates in discussion rounds with the Medical Director.
• Arrives at a medical necessity decision.
• Notifies provider and member of decision.

Job description

Responsibilities

• Accesses the appropriate coverage criteria.
• Performs Utilization Management review in accordance to federal and state mandated regulations, HUM URAC standards and client requirement and/or policies.
• Maintains compliance with regulatory changes affecting Utilization Management.
• Reviews the clinical information and treatment requests against established clinical review criteria, and determine if the criteria is met or not.
• Documents review.
• Protects and secures member’s Protected Health Information (PHI).
• Responds to inbound calls pertaining to reviews in a timely manner, following client-established protocols.
• Participates in discussion rounds with the Medical Director.
• Arrives at a medical necessity decision conducting one of the following:
  • Nurse approves requests that meet the criteria
  • Nurse contractually denies requests excluded in member contract
  • Nurse routes requests not meeting criteria to RMD or refers for Peer-to-peer
• Notifies provider and member of decision through outbound calls.