Clinical Program Nurse II

2 weeks ago

Iloilo City, Philippines Crawford & Company Full time

Overview

Responsible for reviewing medical information to determine if requested treatment is medically necessary and appropriate according to the given standards.

Responsibilities
  • Evaluation of Medical Information
    • Analyzes medical information and applies established criterion to facilitate the utilization review process.
    • Collaborates objectively with peer physicians to facilitate case resolution.
    • Utilizes appropriate resources to perform utilization review process.
    • Documents pertinent information in internal and external communications to support utilization management determinations and case resolutions.
    • Adheres to the given standard operating procedures (SOP) and turnaround time to complete the review process.
    • Demonstrates knowledge and understanding of Broadspire medical department policies and procedures and ability to communicate same with internal/ external customers as necessary.
  • Business Process Support
    • Plans and organizes individual caseload to meet requirements.
    • Communicates effectively with persons involved in the review process as needed.
    • Refers matters beyond limits of authority and expertise to immediate superior for direction.
    • Upholds the Crawford Code of Conduct by protecting the confidentiality of information.
    • Performs other related tasks as required or needed.
    • Demonstrates knowledge and understanding of Broadspire medical department policies and procedures and ability to communicate same with internal/ external customers as necessary.
Qualifications
  • Bachelor's degree in Nursing.
  • Must have an active and in good standing without restriction Philippine RN license.
  • Minimum of one (1) year diverse clinical experience or prior experience in medical bill review or claim/case review.
  • Good communication skills.
  • Proficient in word processing software applications.
  • Analytical skills - Ability to perform basic bill review according to standard operating procedures (SOP).
  • Maintains high degree of professionalism and confidentiality.
  • Ability to multi-task, prioritize and manage time effectively.
  • Interpersonal skills - Able to work independently and as a team member.
  • Keen attention to details.
  • Must complete continuing education requirements mandated by the Professional Regulation Commission.
  • Must complete courses as outlined by Crawford Educational Services.
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