US Registered Nurse

Carelon Global Solutions Philippines; Iloilo; On-site; PHP 250,000 - 450,000; Full time

Job summary

Carelon Global Solutions Philippines is seeking an experienced Registered Nurse to collaborate with healthcare providers and members, promoting appropriate, cost-effective care across the continuum.

You will conduct pre-certification, continued stay reviews, and care coordination, including discharge planning. BSN and active RN license are required; 1 year of acute care or case management experience is expected, with a Master’s degree or related certification as a plus.

Qualifications

• Requires BSN and active unrestricted RN license to practice in applicable states.
• Minimum 1 year of acute care, case management, utilization management, or managed care experience.
• Healthcare-related certification and/or Master’s degree a plus.
• Strong oral, written and interpersonal communication skills.

Responsibilities

• Conducts pre-certification, continued stay review, and care coordination.
• Performs discharge planning and efficiency reviews to ensure appropriate setting of care.
• Collaborates with clinical reviewers/medical directors to ensure quality, cost-effective care.
• Supports accreditation efforts by understanding and applying standards.

Skills

Communication

Problem solving

Interpersonal skills

Education

BSN

Active RN license (US state)

Master’s degree or certifications (a plus)

Job description

Responsible for collaborating with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources. Ensures medically appropriate, high-quality, cost-effective care through assessing the medical necessity of inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting by utilizing the applicable medical policy and clinical guidelines, accurately interpreting benefits, and managed care products, and steering members to appropriate providers, programs or community resources. Works with medical directors in interpreting appropriateness of care and accurate claims payment. May also manage appeals for services denied.

Primary duties may include, but are not limited to:

• Conducts pre-certification, continued stay review, care coordination, or discharge planning for appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.
• Ensures member access to medically necessary, quality healthcare in a cost-effective setting according to contract.
• Consults with clinical reviewers and/or medical directors to ensure medically appropriate, high-quality, cost-effective care throughout the medical management process.
• Collaborates with providers to assess member’s needs for early identification of and proactive planning for discharge planning. Facilitates member care transition through the healthcare continuum and refers treatment plans/plan of care to clinical reviewers as required and does not issue non-certifications.
• Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.

Qualifications

Requires a BSN, current active unrestricted RN license to practice as a health professional in applicable state(s) of the United States, and 1 year of acute care clinical experience or case management, utilization management or managed care experience, which would provide an equivalent background. Healthcare related certification and/or Master’s degree a plus. Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills. For URAC accredited areas the following applies: Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.