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Utilization Review Nurse

3 weeks ago

Manila, National Capital Region, Philippines Crawford Group Full time
The Ideal Candidate

We are seeking a highly skilled Clinical Program Nurse II who is passionate about delivering exceptional results in a fast-paced environment. As a key member of our team, you will be responsible for reviewing medical information to determine if requested treatment is medically necessary and appropriate according to the given standards.

Main Responsibilities:
  • Review and Analysis
    • Reviews medical information to determine if requested treatment is medically necessary and appropriate.
    • Collaborates with peer physicians to facilitate case resolution.
    • Documents pertinent information to support utilization management determinations and case resolutions.
  • Operational Support
    • Provides operational support by communicating effectively with stakeholders.
    • Plays a critical role in business operations by ensuring timely and accurate reviews.
    • Refers complex cases to immediate superiors for direction.
Requirements:
  • Bachelor's degree in Nursing.
  • Active Philippine RN license.
  • Minimum one year diverse clinical experience or prior experience in medical bill review or claim/case review.
  • Excellent analytical and communication skills.
  • Ability to work independently and as part of a team.
  • High level of professionalism and confidentiality.
  • Continuing education requirements mandated by the Professional Regulation Commission.
  • Courses as outlined by Crawford Educational Services.