Clinical Program Nurse II

1 week ago

Manila, Philippines Crawford & Company Full time

Job Description Responsible for reviewing medical information to determine if requested treatment is medically necessary and appropriate according to the given standards. Responsibilities Evaluate medical information and apply established criteria to facilitate the utilization review process. Collaborate objectively with peer physicians to facilitate case resolution. Utilize appropriate resources to perform the utilization review process. Document pertinent information in internal and external communications to support utilization management determinations and case resolutions. Adhere to the given standard operating procedures (SOP) and turnaround time to complete the review process. Demonstrate knowledge and understanding of Broadspire medical department policies and procedures and communicate same with internal/ external customers as necessary. Plan and organize individual caseload to meet requirements. Communicate effectively with persons involved in the review process as needed. Refer matters beyond limits of authority and expertise to immediate superior for direction. Uphold the Crawford Code of Conduct by protecting confidentiality of information. Perform other related tasks as required. Qualifications Bachelor's degree in Nursing. Active Philippine RN license in good standing. Minimum of one (1) year varied clinical experience or prior experience in medical bill review or claim/case review. Good communication skills. Proficient in word processing applications. Analytical skills to perform basic bill review according to 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 detail. Complete continuing education requirements mandated by the Professional Regulation Commission. Complete courses as outlined by Crawford Educational Services. Seniority Level Entry level Employment Type Full-time Job Function Health Care Provider Industry Insurance Location Manila, National Capital Region, Philippines #J-18808-Ljbffr

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