Clinical Program Nurse I

Responsible for auditing in-patient and/or surgical bills to promote excellence in medical bill review and process improvement.

• Medical Bill Review
  
  
  
  • Processes inpatient and/or surgical bills by adhering to the given standard operating procedures (SOP) and turnaround time to complete the task.
  
  
  • Performs bill review process by utilizing appropriate resources.
  
  
  • Clarifies billing discrepancies to analyze and recommend appropriate reimbursement.
  
  
  • Documents pertinent information in the system bill notes to support reimbursement determination.
  
  
  • Performs reconsideration of bills, as per request, to ensure original bill processing determination is appropriate.
  
  
  • Collaborates objectively with peer physicians to facilitate determination of reimbursement.
  
  
  • 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
  
  
  
  • Provides assistance to Business Process Associates and other concerned departments with regards to billing issues, inquiries on fee schedules and/or ground rules for a particular state.
  
  
  • Inform appropriate process owner regarding issues related to calculation of reimbursement.
  
  
  • Communicates effectively with persons involved in case management process as needed.
  
  
  • Liaise with company attorneys to assist in possible litigated claims.
  
  
  • 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.