RN Clinical Utilization & Appeals Specialist IV

MedRisk; Philippines; In loco; PHP 335.000 - 558.000; Tempo pieno

Descrizione del lavoro

MedRisk is seeking a Nurse Utilization and Clinical Advisor Services Analyst IV to apply clinical expertise in evaluating healthcare cases and claims. You will support care appropriateness, cost, and quality improvements by analyzing cases and coordinating with clients and clinical peers.

Responsibilities include adjudicating cases, reviewing denial reconsideration requests, pricing and evaluating claims for coverage, and ensuring compliance with program policies and standards.

Competenze

• Bachelor’s degree or equivalent in a relevant field.
• Active RN license in good standing.
• Experience in healthcare claims or case review required.

Mansioni

• Apply clinical judgment in adjudicating cases and claims.
• Review requests for denial reconsideration and appeals.
• Manually price and evaluate claims for care appropriateness and coverage.
• Provide input to clients per program policies.
• Collaborate with clinical peer reviewers to resolve cases.
• Ensure compliance with company policies and standards.

Conoscenze

Analytical skills

Policy interpretation

Communication clarity

Formazione

Bachelor's degree or equivalent

Descrizione del lavoro

MedRisk is seeking a Nurse Utilization and Clinical Advisor Services Analyst IV to apply clinical expertise in evaluating healthcare cases and claims. You will support care appropriateness, cost, and quality improvements by analyzing cases and coordinating with clients and clinical peers.

Responsibilities include adjudicating cases, reviewing denial reconsideration requests, pricing and evaluating claims for coverage, and ensuring compliance with program policies and standards.