USRN Hiring Manila

Carelon Global Solutions Philippines, Inc.; Taguig; On-site; PHP 2,460,024 - 3,690,037; Full time

Benefits offered by this job

Competitive compensation

Comprehensive benefits

Health and medical insurance

Rewards and recognition programs

Job summary

Carelon Global Solutions Philippines, Inc. is hiring a USRN for its Manila shift. The USRN is responsible for collaborating with healthcare providers and members to promote quality outcomes and optimize member benefits through effective resource use.

This position requires a BSN and a current active unrestricted RN license, as well as strong communication and problem-solving skills.

Carelon specializes in improving healthcare operations with over 9,000 associates across four offices in the Philippines.

Qualifications

• 1 year of acute care clinical experience or experience in case management, utilization management, or managed care.
• For URAC accredited areas: additional communication and analytical skills required.

Responsibilities

• Conducts pre-certification, continued stay review, care coordination, or discharge planning.
• Ensures member access to medically necessary, quality healthcare.
• Collaborates with providers to assess member’s needs for early identification.
• Facilitates member care transition through the healthcare continuum.

Skills

Strong oral communication skills

Strong written communication skills

Problem-solving skills

Analytical skills

Education

BSN

Current active unrestricted RN license

Healthcare related certification or Master’s degree

Job description

Position Title

USRN Hiring Manila Shift

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.

Responsibilities

• 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 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

• BSN required.
• Current active unrestricted RN license to practice in the applicable state(s) of the United States.
• 1 year of acute care clinical experience or experience in case management, utilization management, or managed care; equivalent background acceptable.
• Healthcare related certification and/or Master’s degree a plus.
• Strong oral, written and interpersonal communication skills, problem‑solving skills, facilitation skills, and analytical skills.
• For URAC accredited areas: additional communication and analytical skills required.

Company Overview

Carelon Global Solutions Philippines specializes in contact center operations and clinical nurse operations for Elevance Health. With four offices in the Philippines – two in Manila and two in Iloilo – the company supports a workforce of over 9,000 associates working to improve healthcare operations.

Benefits

We provide competitive compensation and comprehensive benefits, including rewards and recognition programs, health and medical insurance, and best‑in‑class amenities.