US Registered Nurse

Carelon Global Solutions Philippines; Taguig; On-site; PHP 600,000 - 900,000; Full time

Job summary

Carelon Global Solutions Philippines is seeking a skilled healthcare professional to join our clinical management team. The role focuses on promoting appropriate, cost-effective care by evaluating medical necessity for inpatient and outpatient services and guiding members to appropriate resources.

The successful candidate will perform pre-certification, continued stay reviews, care coordination, discharge planning, and collaboration with medical directors to ensure quality outcomes and

Qualifications

• BSN/Active RN license required; Master’s degree or healthcare certification a plus.
• 1 year of acute care, case management, utilization management, or managed care experience preferred.
• Strong oral, written, and interpersonal communication, problem-solving, facilitation, and analytical skills.

Responsibilities

• Conduct pre-certification, continued stay review, care coordination, or discharge planning for appropriateness.
• Ensure access to medically necessary, quality care in cost-effective settings.
• Consult with clinical reviewers/medical directors to ensure appropriate, high-quality, cost-effective care.
• Collaborate with providers for discharge planning and care transition; refer plans to reviewers as required.
• Support accreditation by understanding accrediting and regulatory standards.

Skills

Communication skills

Problem solving

Facilitation

Analytical thinking

Education

BSN degree

RN license

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.