Clinical Program Nurse II

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

• 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.