– Job Highlights –

  • Open to newly board passers.
  • Work onsite set up. Office is located at: Cupang, Alabang, Muntinlupa City.
  • Shifting Schedule

– Job Summary –

A) Primary Responsibilities

  • He/she works with groups of Employees (EEs), and Functional Heads in addition to individuals across a variety of tasks.
  • Maintains acceptable levels of performance including but not limited to attendance, adherence to protocols, customer courtesy, and all other productivity and efficiency targets and objectives.
  • Manages assigned workload within established performance standards.
  • Maintains confidentiality of all information, policies, and procedures as required by the Health Insurance Portability and Accountability Act (HIPAA) protocols.
  • Learns new methods and services as the job requires.
  • Advises supervisor of any potential problems as they become evident.
  • Attends meetings to achieve departmental goals and objectives.
  • Performs other duties as assigned or require

B) Clinical Responsibilities

  • Performs Utilization Management (UM) reviews in accordance with U.S. State/Federal and other mandated regulations. Maintains compliance with regulatory changes affecting UM.
  • Performs UM reviews (prospective/concurrent/retrospective) for inpatient and outpatient services according to the prescribed standards and client requirements and/or policies.
  • Reviews UM requests for services against established clinical review criteria, referring cases not meeting criteria to a physician reviewer or prescribed escalation protocol.
  • Adheres to Department of Labor, State, and company UM timeframe requirements.
  • Coordinates physician reviewer referral as needed and follows up timely to obtain and deliver those results.
  • Tracks status of all UM in progress.
  • Releases UM determinations to claim stakeholders following client-established protocols.
  • Works closely with management team in the ongoing development and implementation of UM programs.
  • Certifies reviews that meet clinical review criteria/guidelines.
  • Adheres to quality standards and State UM guidelines.
  • Maintains all required UM review documentation in the UM software in a timely manner.
  • Serves as first level contact for customer complaint resolution.
  • Responds to inbound telephone calls pertaining to UM reviews in a timely manner, following client-established protocols.
  • Processes customer calls consistent with program specified strategies and customer satisfaction measurements to include but not limited to proper answering procedure, e.g. opening and closing remarks.

– Job Requirements –
Must be a Philippine Registered Nurse (PHRN)

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