Clinical Healthcare Specialist

9 hours ago

Pasay, National Capital Region, Philippines beBeeHealthcare Full time ₱50,000 - ₱68,000
About this role

This Clinical Nurse Case Manager position involves working with patients to ensure they receive the best possible care in a cost-effective manner. The successful candidate will be responsible for conducting medical management reviews and collaborating with clinical reviewers and medical directors to provide high-quality, medically appropriate care.

The ideal candidate will have an active or non-active RN license and at least one year of clinical or hospital experience. They will also be able to utilize client-specific criteria sets and applicable medical policies to make informed decisions about patient care.

Key responsibilities:

  • Conduct UM pre-service, concurrent, retrospective, out-of-network, and appropriateness of treatment setting reviews.
  • Review service requests to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.
  • Utilize client-specific criteria sets (e.g., Milliman or InterQual) and applicable client-specific medical policy and client clinical guidelines for decision-making to either approve or summarize and route to Client's nursing reviewer and/or Client's medical staff for review.
  • 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.
  • Ensure member access to medically necessary, quality healthcare in a cost-effective setting according to the contract.
  • 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.

Required Skills and Qualifications

The ideal candidate should possess excellent communication and analytical skills, with the ability to work collaboratively with various stakeholders. A strong understanding of medical policies, clinical guidelines, and client-specific criteria is essential.

Benefits

We offer a competitive salary and benefits package, including comprehensive health insurance, retirement plan, and paid time off.

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