USRN with UM Exp

2 weeks ago

Manila, National Capital Region, Philippines UST Full time

Responsibilities:

Perform prospective, concurrent, and retrospective reviews of inpatient, outpatient, ambulatory and ancillary services to ensure medical necessity, appropriate length of stay, the intensity of service, and level of care, including appeal requests initiated by providers, facilities, and membersReview, 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 assessmentsEstablish, coordinate, and communicate discharge planning needs with appropriate internal and external entitiesReview patterns of care associated with disease progression; identify contractual services and organize delivery through appropriate channelsResearch and resolve issues related to benefits, member eligibility, non-elective and non-authorized services, coordination of benefits, care coordination as neededDevelop and deliver targeted education for the provider community related to policies, procedures, benefits when appropriateThis position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required Qualifications:Registered Nurse with current, unrestricted US Registered Nurse license 3+ years of direct, clinical nursing experience (an advantage)2+ years' experience in US Healthcare in utilization management or case management MCG Certification will be a plusHealthedge HRCM or Guiding Care experience is a plus

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