Clinical Program Nurse II

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.
  

• 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.