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