Um Nurse
2 weeks ago
UM Nurse SME
Posted today
Job Description
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 members.
- Review, 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) standards.
- Contact appropriate medical and support personnel to identify and recommend an alternative treatment, service levels, length of stays, etc. using approved clinical protocols.
- Follow out-of-area/out-of-network services and make recommendations on patient transfer to in-network services and/or alternative plans of care.
- May establish care plans and coordinate care through the health care continuum including member outreach assessments.
- Establish, coordinate, and communicate discharge planning needs with appropriate internal and external entities.
- Review patterns of care associated with disease progression; identify contractual services and organize delivery through appropriate channels.
- Research and resolve issues related to benefits, member eligibility, non-elective and non-authorized services, coordination of benefits, care coordination as needed.
- Develop and deliver targeted education for the provider community related to policies, procedures, benefits when appropriate.
- This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required.
Requirements:
- Registered Nurse with current, unrestricted US Registered Nurse license
- 3+ years of UM Experience; SME experience an advantage
- MCG Certification will be a plus
- Open to working hybrid (McKinley)
-
Utilization Review Nurse
4 weeks ago
, Metro Manila, Philippines Buscojobs Full timeMakati, National Capital Region - Dempsey Resource Management Inc. Posted 7 days ago Job Description Qualifications: A graduate of Nursing (BSN) Licensed Nurse Must have training, certification, and at least one (1) year experience relevant to the job. Good communication skills. Computer literate with proficiency in MS Office, using MS Word, and MS Excel. ...
-
Occupational Health Nurse
4 weeks ago
, Metro Manila, Philippines Buscojobs Full timeOccupational Health Nurse Location: Makati, National Capital Region Company: Dempsey Resource Management Inc. Posted: 7 days ago Job Description Qualifications: A graduate of Nursing (BSN) Licensed Nurse ust have training, certification, and at least one (1) year experience relevant to the job. ood communication skills. omputer literate with proficiency in...
-
Full Nclex Sponsorship Program + 20K Monthly
2 weeks ago
, Metro Manila, Philippines Buscojobs Full timeOverview Full NCLEX Sponsorship Program 20k Monthly job in Pasay, Camarines Sur. Posted today. Job Description — NCLEX Sponsorship Program SALARY & BENEFITS : Earn while you Learn! 20k Monthly Allowance while reviewing. FREE NCLEX Review & Exam (NO WORK OPERATION, just REVIEW for 3-4 months). Promotion to USRN post with increased compensation upon passing...
-
Staff Nurse
4 weeks ago
, , Philippines Buscojobs Full timeApplying is easy. We manage your application and pay for licensing and visa fees. We have recruited over 8,000 health professionals to the Middle East since 1981. Accommodations provided. Medical coverage. Return airfare. Tax-free income. Types: Nursing, Physicians, Nurse Educators. Registered Nurse Posted 7 days ago Job Description Qualifications: A...
-
, Metro Manila, Philippines Buscojobs Full timeExplore clinical claim review and pre-service review RN jobs in Muntinlupa, where healthcare opportunities are expanding. These roles involve assessing medical claims, ensuring accuracy, and verifying pre-authorization requirements. Professionals in this field play a crucial part in maintaining healthcare standards and optimizing resource allocation. In...
-
Nurse - Clinical Review
1 week ago
, Western Visayas, Philippines WNS Global Services, Inc. Full timeCompany Description HealthHelp - A WNS Company ( is the leader in the field of healthcare utilization and care management. We have gained this position by actively working to change out-of-date practices with a collaborative, non-denial based approach. Our methodology helps payors achieve a higher return on investment, gives providers education programs that...
-
Operations Manager
2 hours ago
Manila, National Capital Region, Philippines PMConsulting Full time ₱1,500,000 - ₱3,000,000 per yearWe are looking for a licensed Philippine Registered Nurse (PHRN) with strong BPO leadership experience to manage operations and lead teams for a Healthcare account. This role combines operational oversight with clinical understanding, ensuring exceptional service delivery, regulatory compliance, and team development in a fast-paced BPO environment.Key...
-
USRN w/ UR Denials + Interqual Experience
31 minutes ago
Manila, National Capital Region, Philippines Omega Healthcare Management Services Inc. Full time ₱900,000 - ₱1,200,000 per yearDuties & ResponsibilitiesWork post discharge, prebill accounts efficiently and effectively on a daily basis to resolve accounts with "no auth numbers, ALOS vs. authorized days or other discrepanciesEvaluates clinical documentation on multiple patient accounts and escalates issues through the established channelsPerform accurate and timely documentation of...
-
Land Acquisition Assistant Manager
2 weeks ago
, Aklan, Philippines Buscojobs Full timeLand Acquisition Assistant Manager - Malvar Job Description Key Responsibilities Develop / create construction annual/midterm plan activities in line with the set KPI by Section Manager/ General Manager. Manage construction and projects based on cost, schedule, quality, safety and environment from start to completion. Confirm and approve activities to...
