Expert Healthcare Decision Maker

2 days ago

Baguio City, Cordillera, Philippines beBeeCare Full time ₱50,000 - ₱68,000
Clinical Nurse Case Manager Job Description

This role involves managing clinical cases to ensure that patients receive medically necessary, quality healthcare in a cost-effective setting.

Job Overview:

The Clinical Nurse Case Manager will be responsible for conducting medical management review activities that require the review of clinical information against client-specific criteria.

Required Skills and Qualifications:
  • A valid and active USRN license is required for this position.
  • At least 1 year of clinical or hospital experience is necessary for success in this role.
  • The ideal candidate will have USRN with RN license and excellent communication skills.
Benefits:
  • Direct employment opportunity with no bond offered through partnerships with multiple companies.
  • The option to choose the company that fits you best.
Responsibilities:
  1. Conduct UM pre-service, concurrent, retrospective, out-of-network, and appropriateness of treatment setting reviews.
  2. Review service requests for compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.
  3. Utilize client-specific criteria sets (e.g., Milliman or InterQual), applicable client-specific medical policy, and client clinical guidelines for decision-making to approve or summarize and route to Client's nursing reviewer and/or Client's medical staff for review.
  4. 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.
  5. Ensure member access to medically necessary, quality healthcare in a cost-effective setting according to the contract.
  6. 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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