US Registered Nurse

Carelon Global Solutions Philippines; Taguig; On-site; PHP 469,000 - 714,000; Full time

Job summary

Carelon Global Solutions Philippines seeks an experienced registered nurse to support care management activities, focusing on pre-certification, discharge planning, and coordinated care across the healthcare continuum.

You will work with clinical reviewers and providers to ensure appropriate, high-quality, cost-effective care in line with medical policy and guidelines. A strong background in acute care or managed care is required.

Qualifications

• Requires BSN and active RN license to practice as a health professional.
• At least 1 year of acute care clinical experience or case management/utilization management experience.
• Healthcare certification and/or Master's degree is a plus.

Responsibilities

• Conducts pre-certification, continued stay review, care coordination, or discharge planning for appropriateness.
• Ensures access to medically necessary, quality healthcare in a cost-effective setting according to contract.
• Consults with clinical reviewers/medical directors to ensure appropriate, cost-effective care.
• Collaborates with providers for discharge planning and care transition; refers plans to reviewers as required.
• Facilitates accreditation by understanding and applying accrediting and regulatory standards.

Skills

Oral communication

Written communication

Interpersonal skills

Problem solving

Facilitation

Analytical skills

Education

BSN

Master's degree (preferred)

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.