Nurse Medical Mgmt I
5 days ago
Position Title:
Nurse Medical Mgmt I (PHL)Shift:
Job Description:
Responsible for collaborating with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources. Ensures medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting by utilizing the applicable medical policy and clinical guidelines, accurately interpreting benefits, and managed care products, and steering members to appropriate providers, programs or community resources. Works with medical directors in interpreting appropriateness of care and accurate claims payment. May also manage appeals for services denied. Primary duties may include, but are not limited to: Conducts pre-certification, continued stay review, care coordination, or discharge planning for appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts. Ensures member access to medically necessary, quality healthcare in a cost effective setting according to contract. Consults with clinical reviewers and/or medical directors to ensure medically appropriate, high quality, cost effective care throughout the medical management process. Collaborates with providers to assess member's needs for early identification of and proactive planning for discharge planning. Facilitates member care transition through the healthcare continuum and refers treatment plans/plan of care to clinical reviewers as required and does not issue non-certifications. Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards. Requires a BSN, current active unrestricted RN license to practice as a health professional in applicable state(s) of the United States, and 1 year of acute care clinical experience or case management, utilization management or managed care experience, which would provide an equivalent background. Healthcare related certification and/or Master's degree a plus. Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills. For URAC accredited areas the following applies: Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
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Nurse Medical Mgmt I
5 days ago
PHL-Taguig City-Alliance Global Tower, th Ave, Corner th St, Uptown Bonifacio, Philippines Carelon Global Solutions Full time $45,000 - $70,000 per yearPosition Title:Nurse Medical Mgmt IShift:Job Description:Responsible for collaborating with healthcare providers and or members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources for more complex medical issues. Ensures medically appropriate, high quality, cost effective care through assessing the...
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Nurse Medical Management
5 days ago
PHL-Taguig City-Alliance Global Tower, th Ave, Corner th St, Uptown Bonifacio, Philippines Carelon Global Solutions Full time ₱60,000 - ₱120,000 per yearPosition Title:Nurse Medical Management (USRN)Shift:Job Description:Responsible for collaborating with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources.Ensures medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient...
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Grievance/Appeals Rep I
5 days ago
PHL-Taguig City-Alliance Global Tower, th Ave, Corner th St, Uptown Bonifacio, Philippines Carelon Global Solutions Full time $40,000 - $60,000 per yearPosition Title:Grievance/Appeals Rep I (PHL)Shift:Job Description:Responsible for reviewing, analyzing and triaging correspondence in accordance with policies and procedures. Primary duties may include, but are not limited to: Conducts investigation and review of incoming correspondence involving provision of service and benefit coverage issues. documents...
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PHRN Trainee
7 days ago
PHL-Taguig City-Alliance Global Tower, th Ave, Corner th St, Uptown Bonifacio, Philippines Carelon Global Solutions Full time $40,000 - $60,000 per yearPosition Title:PHRN TraineeShift:Job Description:Responsible for serving in an interim basis as a nurse trainee in the USRN Clinical Academy while obtaining NCLEX certification and USRN license prior to being deployed to a USRN function.Primary duties may include, but are not limited to:Attend review and USRN Academy Program for purposes of preparing for the...
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2025 - Cobden & Carter -NCLEX Academy Hiring
5 days ago
PHL-Taguig City-Alliance Global Tower, th Ave, Corner th St, Uptown Bonifacio, Philippines Carelon Global Solutions Full time ₱50,000 - ₱80,000 per yearPosition Title:2025 - Cobden & Carter -NCLEX Academy HiringShift:Job Description:Responsible for serving in an interim basis as a nurse trainee in the USRN Clinical Academy while obtaining NCLEX certification and USRN license prior to being deployed to a USRN function.Primary duties may include, but are not limited to:Attend review and USRN Academy Program...
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2025 - Stark Asia -NCLEX Academy Hiring
5 days ago
PHL-Taguig City-Alliance Global Tower, th Ave, Corner th St, Uptown Bonifacio, Philippines Carelon Global Solutions Full time ₱500,000 - ₱1,500,000 per yearPosition Title:2025 - Stark Asia -NCLEX Academy HiringShift:Job Description:Responsible for serving in an interim basis as a nurse trainee in the USRN Clinical Academy while obtaining NCLEX certification and USRN license prior to being deployed to a USRN function.Primary duties may include, but are not limited to:Attend review and USRN Academy Program for...
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PHL-Taguig City-Alliance Global Tower, th Ave, Corner th St, Uptown Bonifacio, Philippines Carelon Global Solutions Full time ₱500,000 - ₱1,500,000 per yearPosition Title:2025 - Find Human Resources -NCLEX Academy HiringShift:Job Description:Responsible for serving in an interim basis as a nurse trainee in the USRN Clinical Academy while obtaining NCLEX certification and USRN license prior to being deployed to a USRN function.Primary duties may include, but are not limited to:Attend review and USRN Academy...
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DRG Clinical Validation Auditor
3 days ago
PHL-Taguig City-Alliance Global Tower, th Ave, Corner th St, Uptown Bonifacio, Philippines Carelon Global Solutions Full time $420,000 - $840,000 per yearPosition Title:DRG Clinical Validation Auditor - ManilaShift:Job Description:"Responsible for auditing inpatient medical records to ensure clinical documentation supports the conditions and DRGs billed and reimbursed. Specializes in review of Diagnosis Related Group (DRG) paid claims.• Primary duties may include but are not limited to:• ...
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USRN Assistant Manager
5 days ago
PHL-Taguig City-Alliance Global Tower, th Ave, Corner th St, Uptown Bonifacio, Philippines Carelon Global Solutions Full time ₱90,000 - ₱108,000 per yearPosition Title:USRN Assistant Manager - For Internal HiringShift:Job Description:Responsible for serving as the operations point of contact for Medical Management day to day operations, including but not limited to, facilitating issue resolution, meeting goals and targets.Primary duties may include, but are not limited to:Acts as a liaison for both internal...
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Staff Nurse
5 days ago
Quezon City, National Capital Region, Philippines The Medical City Full time $320,000 - $480,000 per yearI. Purpose of the PositionThis role is responsible for assisting the staff nurses in monitoring vital signs and providing assistance to patients as needed.II. Key Result Areas | Duties and ResponsibilitiesA. Patient Care AdministrationGathers and records patients' vital signsFinds out and records patients' medical historyEnsures patients' safety and...
