Clinical Nurse Case Manager – USRN

20 hours ago

Manila, National Capital Region, Philippines Nezda Global Full time
Overview

Nezda Technologies Inc. is currently hiring for Clinical Nurse Case Manager - USRN.

Salary: P 50,000 - P 68,000 (with Perks and benefits).

Work Set up: Work From Home

This position is offered through partnerships with multiple companies; you have an option to choose the company that fits you best. This is a direct employment opportunity with no bond.

Qualifications
  • Active and Non-Active USRN License.
  • With at least 1 Year Clinical or Hospital Experience.
  • USRN with RN License.
Responsibilities
  • Conduct UM pre-service, concurrent, retrospective, out of network, and appropriateness of treatment setting.
  • Review service requests to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits and contracts.
  • Utilize client specific criteria sets (e.g., Milliman or InterQual), applicable client specific medical policy and client clinical guidelines for decision making to either approve or summarize and route to Client's nursing reviewer and/or Client's medical staff for review.
  • Responsible for conducting medical management review activities that require the review of clinical information against client-specific criteria as noted above but excludes denial determinations.
  • Ensure member access to medically necessary, quality healthcare in a cost-effective setting according to the contract.
  • Consult with clinical reviewers and/or U.S. licensed medical directors to ensure medically appropriate, high-quality, cost-effective care throughout the medical management process.

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