Utilization Review Nurse

1 day ago

Quezon City, Philippines Private Advertiser Full time

What we offer Salary Package: PHP 50,000 + Sign-On Bonus: PHP 50,000 Work Setup: Onsite at Bridgetowne, Quezon City Schedule: Shifting Schedule Essential Duties and Responsibilities Accurately interpret member benefits and managed care products, and guide members to appropriate providers, programs, or community resources. Collaborate with medical directors to assess the appropriateness of care and ensure the accuracy of medical claims. Conduct pre-certification, continued stay reviews, care coordination, and discharge planning to ensure compliance with applicable criteria, medical policies, member eligibility, benefits, and contracts. Support accreditation efforts by understanding, interpreting, and correctly applying accrediting and regulatory requirements and standards. Ensure member access to necessary, high-quality healthcare in a cost-effective setting as outlined by contract terms. Consult with clinical reviewers and medical directors to ensure that care remains medically appropriate, high-quality, and cost-effective throughout the medical management process. Work closely with providers to identify member needs early and facilitate proactive discharge planning. Coordinate smooth member care transitions across the healthcare continuum. Refer care or treatment plans to clinical reviewers as required (does not issue non-certifications). Minimum Hiring Qualifications Education: Bachelor’s degree in Nursing Experience: Minimum of 2 years of BPO clinical experience (specifically in utilization management, appeals management, or denials). License: Current, active, and unrestricted license to practice as a Registered Nurse (PHRN) . Skills: Strong oral, written, and interpersonal communication skills; problem-solving, facilitation, and analytical skills #J-18808-Ljbffr

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