Job Description

Responsible for reviewing medical information to determine if requested treatment is medically necessary and appropriate according to the given standards.

Responsibilities

Evaluation of Medical Information

Analyzes medical information and applies established criterion to facilitate the utilization review process.
Collaborates objectively with peer physicians to facilitate case resolution.
Utilizes appropriate resources to perform utilization review process.
Documents pertinent information in internal and external communications to support utilization management determinations and case resolutions.
Adheres to the given standard operating procedures (SOP) and turnaround time to complete the review process.
Demonstrates knowledge and understanding of Broadspire medical department policies and procedures and ability to communicate same with internal/ external customers as necessary.

Business Process Support

Plans and organizes individual caseload to meet requirements.
Communicates effectively with persons involved in the review process as needed.
Refers matters beyond limits of authority and expertise to immediate superior for direction.
Upholds the Crawford Code of Conduct by protecting the confidentiality of information.
Performs other related tasks as required or needed.
Demonstrates knowledge and understanding of Broadspire medical department policies and procedures and ability to communicate same with internal/ external customers as necessary.

Qualifications

Bachelor's degree in Nursing.
Must have an active and in good standing without restriction Philippine RN license.
Minimum of one (1) year diverse clinical experience or prior experience in medical bill review or claim/case review.
Good communication skills.
Proficient in word processing software applications.
Analytical skills - Ability to perform basic bill review according to standard operating procedures (SOP).
Maintains high degree of professionalism and confidentiality.
Ability to multi-task, prioritize and manage time effectively.
Interpersonal skills - Able to work independently and as a team member.
Keen attention to details.
Must complete continuing education requirements mandated the Professional Regulation Commission.
Must complete courses as outlined by Crawford Educational Services.

Clinical Program Nurse II