Urgent Hiring | USRN - Project Based

Private Advertiser; Makati; On-site; PHP 420,000 - 660,000; Full time

Benefits offered by this job

Retirement Plan

Medical Plan (HMO) from Day 1

Dental, Medical, and Optical Reimburse

Life and Disability Insurance

Paid Time-Off Benefits

Tuition Fee Reimbursement

Employee Assistance Program (EAP)

Annual Merit Increases

Employee Referral Program

All Mandatory Statutory Benefits

Job summary

Private Advertiser in Metro Manila is seeking a qualified nurse to perform pre-service clinical coverage reviews and determinations based on benefit plans, guidelines, and regulatory requirements.

The role requires USRN and PHRN licenses, at least two years of hospital bedside experience, and strong proficiency with EHRs for reviewing documentation and making determinations.

Qualifications

• Valid and unrestricted USRN and PHRN licenses are required.
• A minimum of 2 years of hospital bedside nursing experience is required.
• Clinical competence in understanding hospital care and care coordination.
• Knowledge in computer navigation.

Responsibilities

• Perform pre-service clinical coverage review of services using benefit plan documents and guidelines.
• Determine medical appropriateness of inpatient and outpatient services based on medical guidelines.
• Conduct non-clinical research to route cases to appropriate health plan teams.
• Review and interpret clinical/medical records submitted by providers.
• Make final determinations in line with clinical and departmental guidelines, adhering to regulatory requirements.
• Maintain productivity and quality goals and document recommendations.

Skills

Nursing

Clinical coordination

Medical documentation

Education

BSN or equivalent

Tools

EHR Systems

Job description

ROLE AND RESPONSIBILITIES

• Function is responsible for performing pre-service clinical coverage review of services that require notification, using applicable benefit plan documents, evidence-based medical policy and nationally recognized clinical guidelines and criteria. Determines medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination.

• Conduct Non-Clinical Research to Support Determinations. Determine that the case is assigned to the appropriate team and health plan for review (e.g., Medicare, Medicaid, Commercial, Dual Special Needs Plan)

• Review Existing Clinical Documentation. Review/interpret clinical/medical records submitted from provider (e.g., office records, test results, prior operative reports)

• Make Final Determinations Based on Clinical and Departmental Guidelines. Understand and adhere to applicable legal/regulatory requirements (e.g., federal/state requirements, HIPAA, CMS, NCQA/URAC accreditation)

• Achieve and Maintain Established Productivity and Quality Goals. Adhere to relevant quality audit standards in performing reviews, making determinations and documenting recommendations.

JOB QUALIFICATIONS

• Valid and unrestricted USRN and PHRN licenses are required

• A minimum of 2 years of hospital bedside nursing experience is required

• Clinical competence in understanding hospital care and care coordination

• Knowledge in computer navigation

WHAT WE OFFER

• Market Total Rewards Package

• Retirement Plan

• Medical Plan (HMO) from Day 1 of employment

• Dental, Medical, and Optical Reimbursements

• Life and Disability Insurance

• Paid Time-Off Benefits

• Sick Leave Conversion

• Tuition Fee Reimbursement

• Employee Assistance Program (EAP)

• Annual Performance Based Merit Increases

• Employee Recognition

• Training and Staff Development

• Employee Referral Program

• Employee Volunteerism Opportunity

• All Mandatory Statutory Benefits