Clinical Case Manager for Medical Claims

1 day ago


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

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.


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