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Healthcare Review Specialist

7 days ago

Cebu City, Central Visayas, Philippines Health Business Solutions LLC Full time

Job Summary:

We are seeking a skilled Utilization Review Coordinator (URC) to oversee patient insurance certification, compliance with governmental regulations related to hospital stays, and the prevention of denials. Embedded within our utilization review management platform are clinical criteria guidelines, streamlining the review and documentation process. The department conducts perspective, concurrent, and retrospective reviews for authorization of Levels of Care (LOCs) and services, engaging with Program Managers, reviewing medical necessity records, and liaising with individuals and their families when necessary.

Key Responsibilities:

  • Evaluate patient records to assess severity of illness and intensity of service.
  • Apply medical necessity screening criteria and clinical knowledge to ensure appropriateness of admissions and length of stays.
  • Conduct initial admission, continuing stay, and 23-hour observation reviews for all patients.
  • Manage case reviews in the electronic utilization review system.
  • Collaborate with payor sources to communicate clinical information and secure hospital reimbursement.
  • Consult with physicians and nursing staff.
  • Participate in interdisciplinary care rounds for effective communication with the care team.
  • Use escalation pathways to resolve identified issues.
  • Document all activities and interactions in the electronic utilization review record.

Required Qualifications:

  • Bachelor's degree in nursing, physical therapy, medical technician, HIMS, or a related medical field.
  • Managed Care or Health Plan experience.
  • Detail-oriented.
  • Effective oral and written communication skills.
  • Moderate computer proficiency – Microsoft Office Suite.
  • Team-oriented approach.
  • Independent functioning and autonomy.