BPO Utilization Reviewer

8 months ago

Taguig City, Philippines Manpower Core Group Inc. Full time

Summary:
The Clinical Review Nurse position assesses the medical appropriateness of proposed treatments and medications for our injured employees, and partners with the Client Claims Adjuster team to expedite medically necessary treatment for each claim. Maintains a solid understanding of Client’s mission, vision, and values. Upholds the standards of the Client organization.

Roles and Responsibilities:
• PH Nurses to review treatment authorization request based on state guidelines and medical necessity and take decision to approve/deny. In case of denial send this to independent panel review to support the decision. Nurses will work with Claims adjuster on denial decision based on risk tolerance to ensure the denial doesn’t adversely affect the claim outcome.
• No licensing requirements. Occupational therapist or registered nurses with clinical background can perform this task.
• Perform Utilization Review activities prospectively, concurrently, or retrospectively in accordance with the appropriate jurisdictional and/or evidence-based guidelines.
• Uses clinical/nursing skills to determine whether all aspects of a patient’s care, at every level, are medically necessary and appropriately delivered.
• Sends letters as needed to prescribing physician(s) and refers to physician advisor as necessary
• Responsible for accurate comprehensive documentation of case management activities in case management system.
• Uses clinical/nursing skills to help coordinate the individual’s treatment program while maximizing quality and cost-effectiveness of care including direction of care to preferred provider networks where applicable.
• Addresses need for job description and appropriately discusses with employer, injured employee and/or provider. Works with employers on modifications to job duties based on medical limitations and the employee’s functional assessment.
• Responsible for helping to ensure injured employees receive appropriate level and intensity of care through use of medical and disability duration guidelines, directly related to the injury and/or assist adjusters in managing medical treatment to drive resolution.
• Communicates effectively with claims adjuster, client, vendor, supervisor, and other parties as needed to coordinate appropriate medical care and return to work.
• Performs clinical assessment via information in medical/pharmacy reports and case files; assesses client’s situation to include psycho social needs, cultural implications, and support systems in place.
• Objectively and critically assesses all information related to the current treatment plan to identify barriers, clarify, or determine realistic goals and objectives, and seek potential alternatives.
• Partners with the adjuster to develop medical resolution strategies to achieve maximal medical improvement or the appropriate outcome.
• Evaluate and update treatment and return to work plans within established protocols throughout the life of the claim.
• Engage specialty resources as needed to achieve optimal resolution (behavioral health program, physician advisor, peer reviews, medical director).
• Partner with adjuster to provide input on medical treatment and recovery time to assist in evaluating appropriate claim reserves.
• Keeps current with market trends and demands.
• Performs other functionally related duties as assigned.

Required Qualifications:
• Bachelor’s degree in nursing (BSN)
• Active unrestricted RN license that can be validated thru PRC website
• 1-2 years of relevant Clinical experience in any medical/surgical department, Orthopedic, Medical/Surgical ICU, Coronary Care Unit (CCU), Rehabilitation, Emergency department
• Written and verbal fluency in English
• Candidate should be willing to work onsite (BGC)
• Candidate should be willing to work in US operation hours

Preferred:
• Proficiency in all Microsoft Office products including Project, Word, Excel, PowerPoint, Visio, and SharePoint
• Knowledge of workers’ compensation laws and regulations, behavioral health, case management practice, URAC standards, ODG, Utilization review, pharmaceuticals to treat pain, pain management process, drug rehabilitation, state workers compensation guidelines, periods of disability, and treatment needed
• Leadership/management/motivational skills as well as analytic and strong organizational skills
• Ability to work in a team environment and to meet or exceed Performance Competencies

  • BPO Utilization Reviewer

    1 week ago

    Taguig, Philippines Manpower Core Group Inc. Full time

    Summary:The Clinical Review Nurse position assesses the medical appropriateness of proposed treatments and medications for our injured employees, and partners with the Client Claims Adjuster team to expedite medically necessary treatment for each claim. Maintains a solid understanding of Client’s mission, vision, and values. Upholds the standards of the...

  • BPO Utilization Reviewer

    7 months ago

    Taguig City, Philippines Manpower Core Group Inc. Full time

    Summary: The Clinical Review Nurse position assesses the medical appropriateness of proposed treatments and medications for our injured employees, and partners with the Client Claims Adjuster team to expedite medically necessary treatment for each claim. Maintains a solid understanding of Client’s mission, vision, and values. Upholds the standards of the...

  • Utilization Reviewer

    8 months ago

    Taguig, Philippines Gratitude Philippines Full time

    Required Qualifications:• Bachelor’s degree in nursing (BSN)• Active unrestricted RN license that can be validated thru PRC website• 1-2 years of relevant Clinical experience in any medical/surgical department, Orthopedic, Medical/Surgical ICU, Coronary Care Unit (CCU), Rehabilitation, Emergency department• Written and verbal fluency in English•...

  • Utilization Reviewer

    8 months ago

    Taguig, Philippines Gratitude Philippines Full time

    Required Qualifications: • Bachelor’s degree in nursing (BSN) • Active unrestricted RN license that can be validated thru PRC website • 1-2 years of relevant Clinical experience in any medical/surgical department, Orthopedic, Medical/Surgical ICU, Coronary Care Unit (CCU), Rehabilitation, Emergency department • Written and verbal fluency in...

  • Utilization Reviewer

    7 months ago

    Taguig, Philippines Gratitude Philippines Full time

    Required Qualifications: • Bachelor’s degree in nursing (BSN) • Active unrestricted RN license that can be validated thru PRC website • 1-2 years of relevant Clinical experience in any medical/surgical department, Orthopedic, Medical/Surgical ICU, Coronary Care Unit (CCU), Rehabilitation, Emergency department • Written and verbal fluency in...

  • Utilization Reviewer

    1 week ago

    Taguig, Philippines Gratitude Philippines Full time

    Roles and Responsibilities:• PH Nurses to review treatment authorization request based on state guidelines and medical necessity and take decision to approve/deny. In case of denial send this to independent panel review to support the decision. Nurses will work with Claims adjuster on denial decision based on risk tolerance to ensure the denial doesn’t...

  • Utilization Reviewer

    8 months ago

    Taguig, Philippines Gratitude Philippines Full time

    Roles and Responsibilities: • PH Nurses to review treatment authorization request based on state guidelines and medical necessity and take decision to approve/deny. In case of denial send this to independent panel review to support the decision. Nurses will work with Claims adjuster on denial decision based on risk tolerance to ensure the denial doesn’t...

  • Utilization Reviewer

    7 months ago

    Taguig, Philippines Gratitude Philippines Full time

    Roles and Responsibilities: • PH Nurses to review treatment authorization request based on state guidelines and medical necessity and take decision to approve/deny. In case of denial send this to independent panel review to support the decision. Nurses will work with Claims adjuster on denial decision based on risk tolerance to ensure the denial doesn’t...

  • Clinical Utilization Review Specialist

    1 month ago

    Taguig, National Capital Region, Philippines Gratitude Philippines Full time

    We are seeking a highly skilled Clinical Utilization Review Specialist to join our team at Gratitude Philippines. This role is responsible for conducting thorough reviews of medical records to ensure compliance with regulatory requirements and company standards.Key Responsibilities:Conduct clinical reviews of medical records to determine medical necessity...

  • Clinical Utilization Specialist

    1 month ago

    Taguig, National Capital Region, Philippines Gratitude Philippines Full time

    Gratitude Philippines: A Leader in HealthcareWe are seeking a skilled Clinical Utilization Specialist to join our team in Taguig. As a key member of our healthcare team, you will play a vital role in reviewing and managing healthcare utilization.About the RoleUtilization Management Review:Clinical Appeals and Denials Handling for Healthcare...

  • Clinical Utilization Specialist

    1 day ago

    Taguig, National Capital Region, Philippines Gratitude Philippines Full time

    At Gratitude Philippines, we are committed to delivering exceptional care and services to our clients. As a Clinical Utilization Specialist, you will play a vital role in ensuring that our patients receive the best possible treatment and care.About UsWe are a dynamic and growing organization dedicated to providing high-quality healthcare services. Our team...

  • BPO Operations Manager

    8 months ago

    Taguig City, Philippines Manpower Core Group Inc. Full time

    Key skills manger operations Healthcare domain Healthcare Operation PH Healthcare Minimum 2 years leadership role in BPO Healthcare Healthcare account BPO Healthcare. Functional Title: Operations Manager. Educational Background: B.S Nursing Qualifications:  8+ years of related experience or equivalent combination of education and experience required...

  • BPO Operations Manager

    7 months ago

    Taguig City, Philippines Manpower Core Group Inc. Full time

    Key skills manger operations Healthcare domain Healthcare Operation PH Healthcare Minimum 2 years leadership role in BPO Healthcare Healthcare account BPO Healthcare. Functional Title: Operations Manager. Educational Background: B.S Nursing Qualifications:  8+ years of related experience or equivalent combination of education and experience required...

  • BPO Operations Manager

    1 week ago

    Taguig, Philippines Manpower Core Group Inc. Full time

    Key skillsmanger operationsHealthcare domainHealthcare OperationPH HealthcareMinimum 2 years leadership role in BPO HealthcareHealthcare accountBPO Healthcare.Functional Title: Operations Manager.Educational Background: B.S NursingQualifications: 8+ years of related experience or equivalent combination of education and experience required to include 2+...

  • Content Review Specialist

    2 months ago

    Quezon City, National Capital Region, Philippines Velasco Outsourcing Company Full time

    Velasco Outsourcing Company is a leading outsourcing provider seeking a highly skilled Content Moderator to join our team. This role offers an excellent opportunity for individuals with strong communication and problem-solving skills.About the RoleWe are looking for a meticulous Content Moderator who can effectively review and manage online content. The...

  • Clinical Utilization Specialist

    1 month ago

    Taguig, National Capital Region, Philippines Manpower Core Group Inc. Full time

    Manpower Core Group Inc. is seeking a skilled Clinical Utilization Specialist - Medical Case Manager to join our team in BGC. This role plays a vital part in ensuring that employees receive the necessary medical care and support to return to work.About the Role:This position involves conducting thorough reviews of treatment authorization requests based on...

  • Healthcare Leader for Critical Care and BPO

    1 day ago

    Quezon City, Taguig, Makati, Muntinlupa, Cebu, Philippines RecruiterPH Full time

    About UsAt RecruiterPH, we pride ourselves on being a leading recruitment agency that connects talented professionals with exciting career opportunities.Job DescriptionWe are seeking a highly skilled and experienced Nurse SME/ Support to join our team. As a critical care expert, you will be responsible for developing innovative approaches to patient care and...

  • Operations Manager

    1 month ago

    Taguig, National Capital Region, Philippines Manpower Core Group Inc. Full time

    Manpower Core Group Inc. is seeking a seasoned Operations Manager to lead our Healthcare Business Process Outsourcing (BPO) team. This key role will be responsible for the overall management of operations, ensuring safe and efficient delivery of services.About the RoleWe are looking for an experienced leader with a strong background in healthcare operations,...

  • USRN SME/ Support

    8 months ago

    Quezon City, Taguig, Makati, Muntinlupa, Cebu, Philippines RecruiterPH Full time

    Job Description Responsibilities: Develops innovative approaches. Serves as a leader/ mentor. Comply with the terms and conditions of the employment contract, company policies and procedures. Sought out as expert. Reviews the work of others. Required Skills: BS Nursing – USRN Active Mainland License. Hospital Experience in Critical Areas (ER, Med...

  • Business Development Associate

    1 week ago

    Taguig, Philippines Ayuda Business Management solution Inc Full time

    Business Development Associate (BPO)Qualifications:•Bachelor’s degree in business administration, Marketing, or related field (preferred).•Proven track record of success in B2B sales or business development, preferably in the BPO or outsourcing industry.•Strong understanding of BPO services, outsourcing trends, and industry dynamics.•Excellent...