PHRN Care Management Associate/Nurse

Siegen HR Solutions; Manila; On-site; PHP 334,800 - 502,200; Full time

Job summary

A healthcare staffing agency is seeking a PHRN Care Management Associate/Nurse in Metro Manila, Philippines. The role involves supporting clinical teams to promote quality outcomes and manage claims. Candidates should possess a BS Nursing degree, an active PHRN license, and experience in a clinical setting. Customer service experience is a plus. This position offers an opportunity to make a significant impact on member benefits and healthcare quality.

Qualifications

• Minimum of three months of prior working experience as a Registered Nurse in a clinical setting.
• Experience in providing direct patient care.
• 1 year of customer service or call-center experience is a plus.

Responsibilities

• Provide support to the clinical and client teams for quality member outcomes.
• Determine customer eligibility by reviewing medical documentation.
• Assess medical appropriateness of claims and manage both new and open claims.

Skills

Clinical assessment

Patient care

Customer service

Education

BS Nursing (BSN) Degree

Active PHRN License

Job description

About the job PHRN Care Management Associate/Nurse

RESPONSIBILITIES:

• To provide support to the clinical team and client team to assist in the promotion of quality member outcomes, to optimize member benefits, and to promote effective use of resources. Supports the procedures that ensure adherence to medical policy and member benefits in providing service that is medically appropriate, high quality, and cost effective.
• Determine customer eligibility by reviewing contractual language and medical documentation, interpret information and make decisions based on facts presented.
• Assess medical appropriateness of claims submitted, and adjust claims as needed.
• Pay all covered claims accurately and timely.
• Manage both new claims and open claims equally and maintains decision turnaround times.
• Understand the client’s operations and corporate compliance, policies and procedures and best practices.

QUALIFICATIONS:

• BS Nursing (BSN) Degree
• Active PHRN License holder
• A minimum of three (3) months of prior working experience as a Registered Nurse in a clinical setting required, three months is equivalent to 480 hours of working experience as an RN
• Working experience as a Registered Nurse means holding an active RN license and providing direct patient care
• Clinical setting includes inpatient hospital, outpatient hospital or clinic
• 1 year of customer service or call‑center experience and minimum of work experience is a plus