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.