Clinical Case Manager for Medical Claims
1 day ago
Job Overview
The Clinical Review Nurse position is a crucial role in assessing the medical appropriateness of proposed treatments and medications for injured employees. As a key partner with the Client Claims Adjuster team, you will expedite medically necessary treatment for each claim while maintaining a solid understanding of the Client's mission, vision, and values.
Key Responsibilities:
- Treatment Authorization Reviews: Conduct thorough reviews of treatment authorization requests based on state guidelines and medical necessity, making informed decisions to approve or deny requests. In cases of denial, collaborate with an independent panel review to support the decision and work with Claims adjusters to ensure the denial doesn't adversely affect the claim outcome.
- Clinical Expertise: Utilize clinical/nursing skills to determine whether all aspects of a patient's care are medically necessary and appropriately delivered, ensuring the highest quality and cost-effectiveness of care.
- Documentation and Communication: Accurately document case management activities in the case management system and effectively communicate with prescribing physicians, refer to physician advisors as necessary, and coordinate with employers, injured employees, and providers to address medical limitations and functional assessments.
- Medical Resolution Strategies: Partner with adjusters to develop medical resolution strategies to achieve maximal medical improvement or the appropriate outcome, evaluating and updating treatment and return-to-work plans within established protocols throughout the life of the claim.
- Specialty Resources: Engage specialty resources as needed to achieve optimal resolution, including behavioral health programs, physician advisors, peer reviews, and medical directors.
Required Qualifications:
- Nursing Background: Bachelor's degree in nursing (BSN) and active unrestricted RN license that can be validated through the PRC website.
- Clinical Experience: 1-2 years of relevant clinical experience in any medical/surgical department, orthopedic, medical/surgical ICU, coronary care unit (CCU), rehabilitation, or emergency department.
- Language Skills: Written and verbal fluency in English.
- Work Environment: Willingness to work onsite and within US operation hours.
-
Clinical Case Manager
1 day ago
Taguig, National Capital Region, Philippines Gratitude Philippines Full timeJob Summary:Gratitude Philippines is seeking a skilled Clinical Case Manager to join our team. As a Clinical Case Manager, you will play a crucial role in ensuring that injured employees receive the appropriate level and intensity of care. Your primary responsibility will be to assess client situations, identify barriers to treatment, and develop medical...
-
Clinical Utilization Specialist
1 month ago
Taguig, National Capital Region, Philippines Manpower Core Group Inc. Full timeManpower 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...
-
Clinical Nurse Case Manager
1 month ago
Taguig, National Capital Region, Philippines Gratitude Philippines Full timeAt Gratitude Philippines, we are committed to providing exceptional care to our clients. We are seeking a highly skilled Clinical Nurse Case Manager to join our team.Job SummaryWe are looking for a seasoned nurse with experience in case management to coordinate the individual's treatment program while maximizing quality and cost-effectiveness of care. As a...
-
Medical Case Manager
1 day ago
Taguig, National Capital Region, Philippines Gratitude Philippines Full timeJob SummaryWe are seeking a highly skilled Medical Case Manager to join our team at Gratitude Philippines. As a Medical Case Manager, you will play a critical role in ensuring that injured employees receive appropriate medical care and return to work.Key Responsibilities:Collaborate with healthcare providers, employers, and adjusters to develop and implement...
-
Medical Necessity Case Manager
1 month ago
Taguig, National Capital Region, Philippines Gratitude Philippines Full timeAbout Gratitude PhilippinesWe are a leading provider of medical management services, dedicated to delivering high-quality solutions that meet the evolving needs of our clients.Job SummaryWe are seeking an experienced Medical Necessity Case Manager to join our team in the Philippines. This is a unique opportunity to work with a dynamic company and contribute...
-
Senior Clinical Claims Specialist
1 month ago
Taguig, National Capital Region, Philippines TASQ Staffing Solutions Full timeAbout TASQ Staffing SolutionsTASQ Staffing Solutions is a leading staffing agency that provides top talent to various industries. As a clinical claims specialist, you will be part of our esteemed team.Salary:$50,000 - $70,000 per year (dependent on experience)Job DescriptionWe are seeking an experienced Senior Clinical Claims Specialist to join our team at...
-
Medical Claims Examiner
4 weeks ago
Taguig, National Capital Region, Philippines TASQ Staffing Solutions Full timeTASQ Staffing Solutions seeks a Medical Claims Examiner to join our team.As a Medical Claims Examiner, you will be responsible for examining medical claims to determine their validity and ensuring that they are processed in accordance with company policies and procedures.The estimated salary for this role is $45,000 - $60,000 per year, depending on...
-
Clinical Nurse Practitioner
2 weeks ago
Taguig, National Capital Region, Philippines TASQ Staffing Solutions Full timeJob Title: Clinical Nurse Practitioner - Accidental Claims SpecialistAbout Us: TASQ Staffing Solutions is a leading provider of healthcare professionals, and we are currently seeking an experienced Clinical Nurse Practitioner to join our team.Salary Range: $80,000 - $120,000 per annum, depending on experience and qualifications.Job Description: As a Clinical...
-
Nursing Professional: Medical Claims Specialist
3 weeks ago
Taguig, National Capital Region, Philippines TASQ Staffing Solutions Full timeJob SummaryTASQ Staffing Solutions seeks a highly skilled Nursing Professional: Medical Claims Specialist to join our team. As a key member of our organization, you will be responsible for managing medical claims from initial review to final resolution.About TASQ Staffing SolutionsWe are a leading staffing agency dedicated to providing exceptional services...
-
Clinical Claims Nurse
2 weeks ago
Taguig, National Capital Region, Philippines TASQ Staffing Solutions Full timeAt TASQ Staffing Solutions, we are seeking a skilled Clinical Claims Nurse to join our team as an Accidental Injury Specialist.Estimated Salary: $40,000 - $60,000 per yearThe ideal candidate will have a Bachelor's degree in nursing and be a PHRN certified professional with 1-2 years of experience in a similar role within the BPO/Shared Services industry....
-
Medical Claims Associate
1 day ago
Taguig, National Capital Region, Philippines TASQ Staffing Solutions Full timeJob OverviewTASQ Staffing Solutions is seeking a highly skilled Medical Claims Associate to join our team. As a key member of our hybrid team, you will play a vital role in processing and resolving medical claims efficiently.Key Responsibilities:Process and investigate medical claims to ensure accurate and timely resolutionCollaborate with healthcare...
-
Clinical Utilization Review Specialist
1 month ago
Taguig, National Capital Region, Philippines Gratitude Philippines Full timeWe 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 day ago
Taguig, National Capital Region, Philippines Gratitude Philippines Full timeAt 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...
-
Clinical Operations Director
1 month ago
Taguig, National Capital Region, Philippines Gratitude Philippines Full timeJob Title: Clinical Operations DirectorLocation: PhilippinesAbout Gratitude Philippines:We are a leading organization in the industry, and we are looking for a highly skilled and experienced Clinical Operations Director to join our team. As a Clinical Operations Director, you will play a key role in the success of our organization.Main...
-
Senior Quality Assurance Specialist
1 month ago
Taguig, National Capital Region, Philippines Gratitude Philippines Full timeJob DescriptionGratitude Philippines is seeking a highly skilled Senior Quality Assurance Specialist to join our team. This role will be responsible for ensuring the highest standards of quality in our clinical services.About the RoleWe are looking for a dedicated professional with strong clinical expertise and a passion for quality assurance. As a Senior...
-
Medical Coding Specialist
1 month ago
Taguig, National Capital Region, Philippines Tasq Staffing Solutions Full timeJob Overview">We are seeking a skilled Medical Coding Specialist to join our team at Tasq Staffing Solutions. As a Medical Coding Specialist, you will play a vital role in ensuring accurate and efficient coding of patient data.About the Role">This is a fantastic opportunity for an experienced medical coder to work onsite at Taguig. The ideal candidate will...
-
Clinical Coding Specialist
3 weeks ago
Taguig, National Capital Region, Philippines Manpower Core Group Inc. Full timeJob DescriptionRole Summary:Clinical Coders play a vital role in the healthcare industry, ensuring that medical records are accurately coded and classified. We are seeking an experienced Clinical Coder to join our team in Manila, Philippines.Responsibilities:Review claims for errors and rejections, correcting them as needed to ensure accurate coding and...
-
Taguig, National Capital Region, Philippines Gratitude Philippines Full timeJob DescriptionAt Gratitude Philippines, we are seeking a highly skilled Quality Assurance Specialist to join our team. In this role, you will play a vital part in ensuring the highest standards of quality care are delivered to our clients.Key Responsibilities:Conduct regular reviews of managed care internal and external claim files to validate consistent...
-
Clinical Coding Specialist
6 days ago
Taguig, National Capital Region, Philippines Manpower Core Group Inc. Full timeOverviewWe are seeking a highly skilled Clinical Coding Specialist to join our team in Manila. This role involves reviewing claims for errors and rejections, ensuring accurate coding and revenue code selection.Job SummaryThis is a key position that requires excellent communication skills, attention to detail, and the ability to work effectively in a...
-
Nursing Education Specialist
1 day ago
Taguig, National Capital Region, Philippines Gratitude Philippines Full timeAbout the Role:As a key member of Gratitude Philippines, we are seeking a highly skilled and experienced Nursing Education Specialist - Clinical Training Expert to join our team. In this pivotal role, you will be responsible for developing and implementing comprehensive education programs that meet the orientation and ongoing competency needs of our...