US Registered Nurse | UM | WFH

2 weeks ago


Metro Manila, Philippines UST Full time

Responsibilities:

Perform prospective, concurrent, and retrospective reviews of inpatient, outpatient, ambulatory and ancillary services Review, research, and prepare documentation related to retrospective review requests and appeals in accordance with local, state, and federal regulatory and designated accreditation (e.g., NCQA) standardsContact appropriate medical and support personnel to identify and recommend an alternative treatment, service levels, length of stays, etc. using approved clinical protocolsFollow out-of-area/out-of-network services and make recommendations on patient transfer to in-network services and/or alternative plans of careMay establish care plans and coordinate care through the health care continuum including member outreach assessments

 

Qualifications:

Registered Nurse with current, unrestricted US Registered Nurse license At least 1 year experience in US Healthcare in utilization management or case management Experience in MCG or InterQual preferred

 

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