BPO Utilization Reviewer
5 days ago
Summary:The Clinical Review Nurse position assesses the medical appropriateness of proposed treatments and medications for our injured employees, and partners with the Client Claims Adjuster team to expedite medically necessary treatment for each claim. Maintains a solid understanding of Client’s mission, vision, and values. Upholds the standards of the Client organization.Roles and Responsibilities:• PH Nurses to review treatment authorization request based on state guidelines and medical necessity and take decision to approve/deny. In case of denial send this to independent panel review to support the decision. Nurses will work with Claims adjuster on denial decision based on risk tolerance to ensure the denial doesn’t adversely affect the claim outcome.• No licensing requirements. Occupational therapist or registered nurses with clinical background can perform this task.• Perform Utilization Review activities prospectively, concurrently, or retrospectively in accordance with the appropriate jurisdictional and/or evidence-based guidelines.• Uses clinical/nursing skills to determine whether all aspects of a patient’s care, at every level, are medically necessary and appropriately delivered.• Sends letters as needed to prescribing physician(s) and refers to physician advisor as necessary• Responsible for accurate comprehensive documentation of case management activities in case management system.• Uses clinical/nursing skills to help coordinate the individual’s treatment program while maximizing quality and cost-effectiveness of care including direction of care to preferred provider networks where applicable.• Addresses need for job description and appropriately discusses with employer, injured employee and/or provider. Works with employers on modifications to job duties based on medical limitations and the employee’s functional assessment.• Responsible for helping to ensure injured employees receive appropriate level and intensity of care through use of medical and disability duration guidelines, directly related to the injury and/or assist adjusters in managing medical treatment to drive resolution.• Communicates effectively with claims adjuster, client, vendor, supervisor, and other parties as needed to coordinate appropriate medical care and return to work.• Performs clinical assessment via information in medical/pharmacy reports and case files; assesses client’s situation to include psycho social needs, cultural implications, and support systems in place.• Objectively and critically assesses all information related to the current treatment plan to identify barriers, clarify, or determine realistic goals and objectives, and seek potential alternatives.• Partners with the adjuster to develop medical resolution strategies to achieve maximal medical improvement or the appropriate outcome.• Evaluate and update treatment and return to work plans within established protocols throughout the life of the claim.• Engage specialty resources as needed to achieve optimal resolution (behavioral health program, physician advisor, peer reviews, medical director).• Partner with adjuster to provide input on medical treatment and recovery time to assist in evaluating appropriate claim reserves.• Keeps current with market trends and demands.• Performs other functionally related duties as assigned.Required Qualifications:• Bachelor’s degree in nursing (BSN)• Active unrestricted RN license that can be validated thru PRC website• 1-2 years of relevant Clinical experience in any medical/surgical department, Orthopedic, Medical/Surgical ICU, Coronary Care Unit (CCU), Rehabilitation, Emergency department• Written and verbal fluency in English• Candidate should be willing to work onsite (BGC)• Candidate should be willing to work in US operation hoursPreferred:• Proficiency in all Microsoft Office products including Project, Word, Excel, PowerPoint, Visio, and SharePoint• Knowledge of workers’ compensation laws and regulations, behavioral health, case management practice, URAC standards, ODG, Utilization review, pharmaceuticals to treat pain, pain management process, drug rehabilitation, state workers compensation guidelines, periods of disability, and treatment needed• Leadership/management/motivational skills as well as analytic and strong organizational skills• Ability to work in a team environment and to meet or exceed Performance Competencies
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BPO Utilization Reviewer
5 days ago
Taguig City, Philippines Manpower Core Group Inc. Full timeSummary: The Clinical Review Nurse position assesses the medical appropriateness of proposed treatments and medications for our injured employees, and partners with the Client Claims Adjuster team to expedite medically necessary treatment for each claim. Maintains a solid understanding of Client’s mission, vision, and values. Upholds the standards of the...
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BPO Utilization Reviewer
5 days ago
Taguig City, Philippines Manpower Core Group Inc. Full timeSummary: The Clinical Review Nurse position assesses the medical appropriateness of proposed treatments and medications for our injured employees, and partners with the Client Claims Adjuster team to expedite medically necessary treatment for each claim. Maintains a solid understanding of Client’s mission, vision, and values. Upholds the standards of the...
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Utilization Reviewer
5 days ago
Taguig, Philippines Gratitude Philippines Full timeRequired Qualifications:• Bachelor’s degree in nursing (BSN)• Active unrestricted RN license that can be validated thru PRC website• 1-2 years of relevant Clinical experience in any medical/surgical department, Orthopedic, Medical/Surgical ICU, Coronary Care Unit (CCU), Rehabilitation, Emergency department• Written and verbal fluency in English•...
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Utilization Reviewer
5 days ago
Taguig, Philippines Gratitude Philippines Full timeRequired Qualifications: • Bachelor’s degree in nursing (BSN) • Active unrestricted RN license that can be validated thru PRC website • 1-2 years of relevant Clinical experience in any medical/surgical department, Orthopedic, Medical/Surgical ICU, Coronary Care Unit (CCU), Rehabilitation, Emergency department • Written and verbal fluency in...
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Utilization Reviewer
5 days ago
Taguig, Philippines Gratitude Philippines Full timeRequired Qualifications: • Bachelor’s degree in nursing (BSN) • Active unrestricted RN license that can be validated thru PRC website • 1-2 years of relevant Clinical experience in any medical/surgical department, Orthopedic, Medical/Surgical ICU, Coronary Care Unit (CCU), Rehabilitation, Emergency department • Written and verbal fluency in...
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Utilization Reviewer
5 days ago
Taguig, Philippines Gratitude Philippines Full timeRoles and Responsibilities:• PH Nurses to review treatment authorization request based on state guidelines and medical necessity and take decision to approve/deny. In case of denial send this to independent panel review to support the decision. Nurses will work with Claims adjuster on denial decision based on risk tolerance to ensure the denial doesn’t...
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Utilization Reviewer
5 days ago
Taguig, Philippines Gratitude Philippines Full timeRoles and Responsibilities: • PH Nurses to review treatment authorization request based on state guidelines and medical necessity and take decision to approve/deny. In case of denial send this to independent panel review to support the decision. Nurses will work with Claims adjuster on denial decision based on risk tolerance to ensure the denial doesn’t...
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Utilization Reviewer
5 days ago
Taguig, Philippines Gratitude Philippines Full timeRoles and Responsibilities: • PH Nurses to review treatment authorization request based on state guidelines and medical necessity and take decision to approve/deny. In case of denial send this to independent panel review to support the decision. Nurses will work with Claims adjuster on denial decision based on risk tolerance to ensure the denial doesn’t...
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BPO Operations Manager
5 days ago
Taguig City, Philippines Manpower Core Group Inc. Full timeKey skills manger operations Healthcare domain Healthcare Operation PH Healthcare Minimum 2 years leadership role in BPO Healthcare Healthcare account BPO Healthcare. Functional Title: Operations Manager. Educational Background: B.S Nursing Qualifications: 8+ years of related experience or equivalent combination of education and experience required...
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BPO Operations Manager
5 days ago
Taguig City, Philippines Manpower Core Group Inc. Full timeKey skills manger operations Healthcare domain Healthcare Operation PH Healthcare Minimum 2 years leadership role in BPO Healthcare Healthcare account BPO Healthcare. Functional Title: Operations Manager. Educational Background: B.S Nursing Qualifications: 8+ years of related experience or equivalent combination of education and experience required...
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BPO Operations Manager
5 days ago
Taguig, Philippines Manpower Core Group Inc. Full timeKey skillsmanger operationsHealthcare domainHealthcare OperationPH HealthcareMinimum 2 years leadership role in BPO HealthcareHealthcare accountBPO Healthcare.Functional Title: Operations Manager.Educational Background: B.S NursingQualifications: 8+ years of related experience or equivalent combination of education and experience required to include 2+...
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Business Development Associate
5 days ago
Taguig, Philippines Ayuda Business Management solution Inc Full timeBusiness Development Associate (BPO)Qualifications:•Bachelor’s degree in business administration, Marketing, or related field (preferred).•Proven track record of success in B2B sales or business development, preferably in the BPO or outsourcing industry.•Strong understanding of BPO services, outsourcing trends, and industry dynamics.•Excellent...
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Business Development Associate
5 days ago
Taguig, Philippines Ayuda Business Management solution Inc Full timeBusiness Development Associate (BPO) Qualifications: •Bachelor’s degree in business administration, Marketing, or related field (preferred). •Proven track record of success in B2B sales or business development, preferably in the BPO or outsourcing industry. •Strong understanding of BPO services, outsourcing trends, and industry...
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USRN SME/ Support
5 days ago
Quezon City, Taguig, Makati, Muntinlupa, Cebu, Philippines RecruiterPH Full timeJob Description Responsibilities: Develops innovative approaches. Serves as a leader/ mentor. Comply with the terms and conditions of the employment contract, company policies and procedures. Sought out as expert. Reviews the work of others. Required Skills: BS Nursing – USRN Active Mainland License. Hospital Experience in Critical Areas (ER, Med...
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Business Development Associate
5 days ago
Taguig, Philippines Ayuda Business Management solution Inc Full timeBusiness Development Associate (BPO) Qualifications: •Bachelor’s degree in business administration, Marketing, or related field (preferred). •Proven track record of success in B2B sales or business development, preferably in the BPO or outsourcing industry. •Strong understanding of BPO services, outsourcing trends, and industry...
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Taguig, Philippines Neksjob Corporation Full time--ONLY THOSE APPLICANTS WHO ALREADY HAVE THE RIGHT TO LIVE AND WORK IN THIS COUNTRY ARE ELIGIBLE TO APPLY FOR THIS ROLE—Do you have a passion for training and development? This is for you!POSITION TITLE: BPO Training and Development Associate ManagerLOCATION: TaguigOTHERS:Project Shift Schedule: Mid ShiftProject Rest Day: Weekends offOVERALL PURPOSE:Client...
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Taguig, Philippines Neksjob Corporation Full time--ONLY THOSE APPLICANTS WHO ALREADY HAVE THE RIGHT TO LIVE AND WORK IN THIS COUNTRY ARE ELIGIBLE TO APPLY FOR THIS ROLE— Do you have a passion for training and development? This is for you! POSITION TITLE: BPO Training and Development Associate Manager LOCATION: Taguig OTHERS: Project Shift Schedule: Mid Shift Project Rest Day: Weekends off OVERALL...
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USRN SME/ Support
5 days ago
Quezon City, Taguig, Makati, Muntinlupa, Cebu, Philippines RecruiterPH Full timeJob Description Responsibilities: Develops innovative approaches. Serves as a leader/ mentor. Comply with the terms and conditions of the employment contract, company policies and procedures. Sought out as expert. Reviews the work of others. Required Skills: BS Nursing – USRN Active Mainland License. Hospital Experience in Critical Areas (ER, Med...
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Taguig, Philippines Neksjob Corporation Full time--ONLY THOSE APPLICANTS WHO ALREADY HAVE THE RIGHT TO LIVE AND WORK IN THIS COUNTRY ARE ELIGIBLE TO APPLY FOR THIS ROLE— Do you have a passion for training and development? This is for you! POSITION TITLE: BPO Training and Development Associate Manager LOCATION: Taguig OTHERS: Project Shift Schedule: Mid Shift Project Rest Day: Weekends off OVERALL...
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Taguig, Philippines Neksjob Corporation Full timeSkills and Qualifications: ✔️ Must have at least 7 years of experience in Training and Development ✔️ Must have at least 2 years of Contact Center or BPO industry experience ✔️ Must have at least 5 years of experience as lead ✔️ Experience in business training, professional development, research and workshops is an advantage ✔️ Excellent...
