UR Nurse (USRN)

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

Pay: Up to Php90,000.00 per hour

Work Location: Hybrid remote in Makati City