UR Nurse (USRN)
- Makati City, Metro Manila
- Permanent
- Full-time
- Facilitate verbal and written communication with employees, employers, providers of care, and adjusters.
- Gather medical data to evaluate the necessity of medical treatment and functional capabilities.
- Insure timely processing of billings, utilization issues, and/or referral decisions.
- Resolve, negotiate, and make recommendations regarding medical care.
- Compare medical information to establish criteria (medical standards) and determine appropriateness of treatment and length of treatment.
- Determine appropriateness of referrals to peer advisors.
- Maintain and monitor volume and cost of peer advisor reviews for management report.
- Perform and maintain research, documentation, statistics, and auditing information on all types of medical providers, procedures, scopes of practice, and professional organizations.
- Respond promptly and expertly to telephone inquiries, verbal or written communications from providers, UM department staff, and others.
- Function as a resource to medical audit, other UM department staff, customers, and outside agencies.
- Assist claims professional in compensability issues involving ICD-10 codes, medical service providers, treatment parameters, dates of service, etc.
- Provide appropriate, adequate, and timely reports to management, accurately reflecting activities and results.
- Review application for patient admission and approve admission or refer case to peer advisor for review and course of action when case fails to meet admission standards.
- Attend training/educational classes as appropriate.
- Coordinate activities of staff in supervisor's absence, where applicable.
- Must actively participate in QM monitoring and strive to achieve departmental standards and objectives.
- Perform other duties and responsibilities as deemed necessary and assigned.
- An active Nursing license in the Philippines and in the mainland US
- One (1) year of experience in Utilization Management/Review (experience in Workers Compensation is preferred, but not required)
- Demonstrated knowledge of ICD-10 codes, the utilization review process, and use of criteria.
- Excellent verbal and written communication, organizational, and leadership skills.
- Proficiency in MS Word and Excel and general computer literacy, working with dual screens
- Strong analytical, interpersonal, and time management skills are also required
- Willing to report on-site in Makati