Staff Nurse

STAFFWISE SOLUTIONS INC.; Pasig; On-site; PHP 279,000 - 446,000; Full time

Job summary

STAFFWISE SOLUTIONS INC. seeks a Clinical Documentation Specialist to review and validate medical records for HMO claims and pre-authorizations.

You will coordinate with hospitals and providers to obtain missing documents and ensure records are complete and accurate, aligning with regulations and internal policies. Strong attention to detail, excellent communication, and proficiency in MS Office are essential.

Qualifications

• Bachelor's degree in a health field is required.
• Experience in HMO, healthcare BPO, hospital, or medical records is preferred.
• Knowledge of medical terminology and healthcare processes.
• Familiarity with EMR/EHR systems is an advantage.
• Understanding of HMO operations, medical claims, and regulations is helpful.
• Proficiency in MS Office (Excel, Word).
• Excellent attention to detail and organizational skills.
• Strong written and verbal communication skills.
• Ability to manage multiple tasks within turnaround times.

Responsibilities

• Review and validate clinical documents for HMO claims and pre-authorizations.
• Ensure medical records are complete and accurate with diagnoses and procedures.
• Coordinate with hospitals and providers to obtain missing documentation.
• Verify documents meet HMO guidelines, regulatory requirements, and internal policies.
• Support Claims, Utilization Management, and Medical Review teams with complete documentation.
• Maintain confidentiality of member health information per Data Privacy Act and policies.
• Identify discrepancies and escalate complex cases to the appropriate team.
• Maintain organized electronic records and update in the HMO information system.
• Assist in documentation audits, QA initiatives, and process improvements.
• Prepare reports on documentation status, turnaround time, and compliance metrics.

Skills

Attention to detail

Microsoft Office (Excel, Word)

Strong written and verbal comms

Multitasking

Education

Bachelor's degree in Nursing, Medical Technology, Pharmacy, Physical Therapy, Healthcare Administration, or allied health

Tools

EMR/EHR systems

Job description

Key Responsibilities

• Review and validate clinical documents submitted in support of HMO claims, pre-authorizations, and medical reviews.
• Ensure medical records are complete, accurate, and consistent with the member's diagnosis, treatment, and procedures.
• Coordinate with hospitals, clinics, physicians, and healthcare providers to obtain missing or incomplete documentation.
• Verify that submitted clinical documents meet HMO guidelines, regulatory requirements, and internal policies.
• Support Claims, Utilization Management, and Medical Review teams by providing complete and accurate documentation.
• Maintain confidentiality and security of member health information in accordance with the Data Privacy Act and company policies.
• Identify documentation discrepancies and escalation complex cases to the appropriate clinical or medical management team.
• Maintain organized electronic records and update documentation in the HMO information system.
• Assist in documentation audits, quality assurance initiatives, and process improvement activities.
• Prepare reports related to documentation status, turnaround time, and compliance metrics.

Key Responsibilities

• Review and validate clinical documents submitted in support of HMO claims, pre-authorizations, and medical reviews.
• Ensure medical records are complete, accurate, and consistent with the member's diagnosis, treatment, and procedures.
• Coordinate with hospitals, clinics, physicians, and healthcare providers to obtain missing or incomplete documentation.
• Verify that submitted clinical documents meet HMO guidelines, regulatory requirements, and internal policies.
• Support Claims, Utilization Management, and Medical Review teams by providing complete and accurate documentation.
• Maintain confidentiality and security of member health information in accordance with the Data Privacy Act and company policies.
• Identify documentation discrepancies and escalation complex cases to the appropriate clinical or medical management team.
• Maintain organized electronic records and update documentation in the HMO information system.
• Assist in documentation audits, quality assurance initiatives, and process improvement activities.
• Prepare reports related to documentation status, turnaround time, and compliance metrics.

Qualifications

• Bachelor's degree in Nursing, Medical Technology, Pharmacy, Physical Therapy, Healthcare Administration, or any allied health-related course.
• Experience in an HMO, healthcare BPO, hospital, medical records, claims processing, or utilization management is preferred.
• Knowledge of medical terminology, clinical documentation, and healthcare processes.
• Familiarity with Electronic Medical Records (EMR/EHR) systems is an advantage.
• Understanding of HMO operations, medical claims, and healthcare regulations is preferred.
• Proficient in Microsoft Office applications, particularly Excel and Word.
• Excellent attention to detail and organizational skills.
• Strong written and verbal communication skills.
• Ability to manage multiple tasks while meeting established turnaround times.