The Role
Provides utilization management and review services for insurers, clients, and injured employees. Evaluates medical necessity, treatment appropriateness, admissions, referrals, billing issues, and clinical documentation using medical criteria and ICD-10 codes. Communicates with providers, adjusters, employees, and employers; prepares management reports; supports audits and claims professionals; and participates in quality monitoring. The role requires active Philippine and US nursing licenses and on-site work in Makati.
Summary Generated by Built In
Our US-based client, a premier multiline claims services provider, is looking for USRNs to be part of their team at their Philippine-based site. The role will provide utilization management services for clients, insurers, and injured employees to promote quality medical care in a prompt, cost-effective manner.
Primary Duties and Responsibilities:
- 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.
Qualifications:
- 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
Skills Required
- Active nursing license in the Philippines
- Active nursing license in a mainland US jurisdiction
- One year of experience in utilization management or utilization review
- Experience in workers compensation
- Knowledge of ICD-10 codes
- Knowledge of the utilization review process and use of medical criteria
- Excellent verbal and written communication skills
- Organizational and leadership skills
- Proficiency in Microsoft Word and Microsoft Excel
- General computer literacy and ability to work with dual screens
- Strong analytical, interpersonal, and time management skills
- Willingness to report on-site in Makati
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The Company
What We Do
Genfinity Philippines, Inc. is a consulting firm focused on enabling excellence in the Philippines' allied health workforce and assisting companies in capitalizing on opportunities within the Philippine BPM support industry.
