Clinical Utilization Specialist

1 month ago


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

Manpower 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 state guidelines and medical necessity, making informed decisions to approve or deny them, and communicating with adjusters to ensure seamless claim resolution.
  • The ideal candidate will possess strong clinical skills, excellent communication abilities, and a deep understanding of workers' compensation laws and regulations.
  • This is a fantastic opportunity for experienced nurses or occupational therapists looking to apply their expertise in a case management setting.

Responsibilities:

  • Treatment Review: Conduct thorough assessments of treatment plans, identifying medically necessary treatments and services, and collaborating with adjusters to develop effective resolution strategies.
  • Clinical Coordination: Coordinate individualized treatment programs with healthcare providers, employers, and employees to ensure timely and cost-effective care.
  • Documentation and Communication: Maintain accurate records of case management activities and communicate effectively with stakeholders, including clients, vendors, and internal teams.
  • Return-to-Work Support: Collaborate with employers and employees to develop job modifications and return-to-work plans that meet their needs and promote successful reintegration into the workforce.

Requirements:

  • A bachelor's degree in nursing (BSN) or a related field.
  • An active unrestricted RN license.
  • At least 1-2 years of relevant clinical experience in any medical/surgical department, orthopedic, medical/surgical ICU, coronary care unit (CCU), rehabilitation, emergency department.
  • Excellent written and verbal communication skills.

Preferred Qualifications:

  • Proficiency in Microsoft Office products, including Project, Word, Excel, PowerPoint, Visio, and SharePoint.
  • Knowledge of workers' compensation laws and regulations, behavioral health, case management practice, URAC standards, ODG, utilization review, pharmaceuticals to treat pain, pain management process, drug rehabilitation, state workers compensation guidelines, periods of disability, and treatment needed.

Estimated Salary: $65,000 - $85,000 per year, depending on experience. We offer a comprehensive benefits package, including medical, dental, vision, and retirement savings plans. If you are a motivated and detail-oriented professional with a passion for delivering exceptional patient care, we encourage you to apply for this exciting opportunity.



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