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Utilization Review Concurrent Review Nurse

3 months ago

Manila, National Capital Region, Philippines Omega Healthcare Management Services Inc. Full time

JOB PURPOSE:

This position is responsible for clinical review of medical records against clinical guidelines (Interqual, MCG, CMS, etc.) to prove medical necessity of medical services provided to the patient and ensure maximum coverage through insurance benefits.

PRIMARY DUTIES & RESPONSIBILITIES:

Utilization Review Nurse duties include but are not limited to:

Review electronic medical records of emergency department admissions and screen for medical necessityUse InterQual and MCG criteria to review for medical necessityParticipate in telephonic or chat discussions with admitting physicians relative to documentation and patient admission statusEnter clinical review information into the system and in the assigned client's EMR or transmission to insurance companies for authorization Qualifications:Active USRN license (any state)3-year clinical experience in the acute setting1-year minimum Utilization Review experience with acute admissions and concurrent reviewsInterqual experienceProficiency in MS toolsSolid understanding of anatomy & physiology, including how body systems function and an understanding of disease processes Comprehensive understanding of Medical TerminologyExcellent customer service skills: communicates clearly and effectivelyCommunicating effectively in writing as appropriate for the needs of the audienceProfessional and effective interaction skills with co-workers, clients, providers, and vendorsProven ability to work well individually and as a team memberStrong attention to detailAbility to follow company and account-specific standard operating procedures and policiesAbility to adapt to constantly changing environmentAbility to prioritize and organize multiple tasks by remaining focused and quality-driven at all tasks at handAbility to remain organized with multiple interruptionsAbility to make decisions independently without bypassing any company and account-specific standard operating procedures and policiesAbility to comfortably receive constructive feedback