Utilization Review & Care Coordination Specialist

Health Business Solutions LLC; Cebu City; On-site; PHP 350,000 - 550,000; Full time

Job summary

Health Business Solutions LLC in the Philippines seeks a skilled Utilization Review Coordinator to oversee patient insurance certification, ensure medical necessity and minimize denials. The URC will work within our utilization review platform to support LOC determinations and liaise with physicians, payors, and families as needed.

Responsibilities include evaluating records, applying criteria, performing initial and concurrent reviews, and documenting all activities while ensuring

Qualifications

• Bachelor’s degree in nursing, physical therapy, medical technician, HIMS, or a related medical field.
• Managed Care or Health Plan experience.
• Detail-oriented.
• Effective oral and written communication skills.
• Moderate computer proficiency – Microsoft Office Suite.
• Team-oriented approach.
• Independent functioning and autonomy.

Responsibilities

• Evaluate patient records to assess severity of illness and intensity of service.
• Apply medical necessity screening criteria and clinical knowledge to ensure appropriateness of admissions and length of stays.
• Conduct initial admission, continuing stay, and 23-hour observation reviews for all patients.
• Manage case reviews in the electronic utilization review system.
• Collaborate with payor sources to communicate clinical information and secure hospital reimbursement.
• Consult with physicians and nursing staff.
• Participate in interdisciplinary care rounds for effective communication with the care team.
• Use escalation pathways to resolve identified issues.
• Document all activities and interactions in the electronic utilization review record.
• Enhance customer satisfaction among patients, families, physicians, internal and external partners, payors, and vendors.
• Submit Initial and Concurrent Authorizations to insurance companies.
• Verify client insurance coverage for authorization submission.
• Coordinate with insurance companies to resolve billing or authorization issues.
• Communicate Billing and Payroll questions from Program Managers and ensure accurate documentation before billing claims.
• Review Service Verification Forms and Time sheets to ensure precise payroll processing.
• Participate in state and local audits.
• Adhere to policies, procedures, regulations, and standards governing the agency.
• Maintain strict confidentiality according to Federal and State guidelines.
• Uphold the Professional Code of Ethics.
• Other duties as assigned.

Skills

Detail-oriented

Oral and written communication

Team-oriented

Independent functioning

Education

Bachelor’s degree in nursing or related medical field

Tools

Microsoft Office Suite

Job description

Health Business Solutions LLC in the Philippines seeks a skilled Utilization Review Coordinator to oversee patient insurance certification, ensure medical necessity and minimize denials. The URC will work within our utilization review platform to support LOC determinations and liaise with physicians, payors, and families as needed.

Responsibilities include evaluating records, applying criteria, performing initial and concurrent reviews, and documenting all activities while ensuring