US Registered Nurses

SAGILITY PHILIPPINES B.V. BRANCH OFFICE; Philippines; On-site; PHP 300,000 - 600,000; Full time

Job summary

SAGILITY PHILIPPINES B.V. BRANCH OFFICE in Quezon City, Philippines is seeking experienced US Registered Nurses to review medical cases, assess appropriateness of care, and process prior authorization requests in line with insurer policies.

You will evaluate services, determine level of care for inpatient and outpatient settings, and ensure timely, evidence-based reviews in collaboration with Medical Directors and care teams.

Job description

Job title:

US Registered Nurses

Job Description:

• Documents all activities in the appropriate system(s) on a timely basis
• Reviews individual medical cases to confirm that they are getting the most appropriate care.
• Weighs the patient's situation against the policy held by the patient, the standards of the insurance company, and the costs which may be involved in treatment.
• Promote the quality and cost effectiveness of medical care by applying clinical knowledge and the appropriate application of policies and guidelines to prior authorization requests.
• Ensures that prior authorization requests are completed in a timely fashion to meet contractual requirements and that all reviews are conducted using nationally recognized and evidence-based standards.
• Evaluates the pre-service authorization request received for scheduled inpatient admissions, ambulatory surgeries, and outpatient services and out of network providers
• Determines the appropriate level of care for patient stays in acute care facilities in compliance with acute care guidelines; prior authorization medical necessity review, including determination of appropriate provision of observation care, outpatient or inpatient rehabilitation services, DME, Home Health and other ancillary healthcare services in compliance with approved care guidelines
• Accurate, thorough and efficient review of authorization requests
• Timely review of prior authorization requests, both inpatient and outpatient
• Acute hospital pre-admission / Skilled Nursing Facility / Hospice and other Long Term Care facilities
• Surgical / Diagnostic procedures / Therapies / Durable Medical Equipment and Home Care;
• Determines utilization decisions based upon nationally recognized and evidence based guidelines
• Reviews prior authorization requests with Medical Directors as directed

Location:

Quezon City, PhilippinesPhilippines