Healthcare Advocate

1 week ago

Pasig, National Capital Region, Philippines Optum Full time

As a member of our team, you will be part of a diverse and inclusive organization that values diversity and promotes equality. We strive to create a healthy work environment where everyone has the opportunity to thrive.

About the Role

This position involves working with various nurse licensure and certification based on role and grade level. The function is responsible for utilization management which includes Concurrent Review (on-site or telephonic Inpatient Care Management).

We are looking for individuals who can perform reviews of current inpatient services, determine medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination.

Main Tasks:

  • Conduct initial and concurrent review of inpatient cases applying MCG criteria or InterQual Criteria for approval and sending to Medical Directors if review is necessary for determining an adverse determination.
  • Discuss cases with facility healthcare professionals to obtain plans-of-care.
  • Collaborate with UnitedHealthcare Medical Directors on performing utilization management.
  • Participate in discussions with the Clinical Services team to improve the progression of care to the most appropriate level.
Required Skills
  • Bachelor's Degree in Nursing.
  • 1+ years Clinical Experience (e.g., Hospital, Company, School, etc.).
  • Active USRN License.

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