Requirements:
- Must have an Active PRC Nursing License.
- At least 1 year of cumulative clinical bedside care experience (hospital, clinic, healthcare facility, etc.) or business process experience (healthcare data management), or any combination which would provide an equivalent background.
- Experience with daily operations in a clinical, managed care, hospital care setting including working with provider systems and medical providers is an advantage.
- Prior Utilization Management or Prior Authorization Clinical Experience is an advantage, but not required.
- Role requires strong oral, written, and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
- Amenable to do review/work on a remote setup (WFH) and willing to work at Pasay City site in casework on-site resumes.
- Must have a minimum of 25mbps wired internet speed.
Responsibilities:
- Review service requests to ensure compliance with applicable criteria, medical policy, member eligibility, benefits, and contracts.
- Route cases to client medical staff for further review when a service or admission does not meet medical necessity, place of service, or benefits criteria.
- Work with clinical reviewers and medical directors in interpreting appropriateness of care and conducting claims reviews utilizing the member’s benefit contract and health plan guidelines.
- Process incoming requests, collection of information needed for review from providers.
- Determine contract and benefit eligibility, obtain intake demographic information from callers and/or faxes.
More Information
- Salary Offer 25,000 - 30,000
- Educational Attainment Bachelor's Degree
- Benefits 13th month pay, Overtime pay, Work from home, Others
- # of Job Vacancies 100+
