Healthcare Professional

2 days ago

San Juan, National Capital Region, Philippines beBeeNursing Full time ₱50,000 - ₱68,000

As a Clinical Nurse Case Manager, you will play a vital role in ensuring members receive medically necessary, quality healthcare in a cost-effective setting. This position is offered through partnerships with multiple companies, allowing you to choose the company that best fits your needs.

Key Responsibilities:
  • Conduct pre-service, concurrent, retrospective, and out-of-network medical reviews to ensure appropriateness of treatment settings.
  • Review service requests to verify compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.
  • Utilize client-specific criteria sets (e.g., Milliman or InterQual) and clinical guidelines for decision-making to approve or summarize and route to Client's nursing reviewer and/or medical staff for review.
  • Ensure member access to quality healthcare by conducting medical management review activities that require the review of clinical information against client-specific criteria.
  • Consult with clinical reviewers and/or U.S. licensed medical directors to ensure medically appropriate, high-quality care throughout the medical management process.

The ideal candidate will possess an active and non-active USRN license, at least one year of clinical or hospital experience, and a RN license.

Benefits:
  • Work-from-home opportunity
  • Direct employment opportunity with no bond required
  • Option to choose from multiple partner companies

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