Clinical Healthcare Specialist

1 day ago

Taguig, National Capital Region, Philippines beBeeCase Full time ₱50,000 - ₱68,000
Job Description

We are seeking an experienced Clinical Nurse Case Manager to conduct medical management reviews, review service requests and ensure member access to quality healthcare in a cost-effective setting.

Responsibilities:

  • Conduct UM pre-service, concurrent, retrospective, out-of-network, and appropriateness of treatment setting reviews to guarantee medically necessary care.
  • Review service requests to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.
  • Utilize client-specific criteria sets, applicable client-specific medical policy, and clinical guidelines for decision making to provide high-quality care.
  • Responsible for conducting medical management review activities that require the review of clinical information against client-specific criteria.
  • Ensure member access to quality, cost-effective healthcare according to the contract, adhering to regulatory standards.
  • 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.

Requirements:

  • Active USRN License and at least one year of experience as a Clinical Nurse or Hospital staff member.
  • USRN with RN License.

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