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Posted:1 Month
Duration of employment:
Permanent
Career field:
Health and Safety
Salary (Monthly):
Less than 35,000 PHP
Qualification required:
Bachelor degree
Minimum experience required:
2 years
Location of Job:
Unit 8B, 8th Floor of Cyber and Fashion Mall, Eastwood City, Bagumbayan, Quezon City
Description:
Job Responsibilities
• Clinical Review & Utilization Management
Evaluate medical records and conduct utilization reviews to ensure services provided are medically necessary and aligned with patient diagnoses and healthcare guidelines.
• Medical Claims Validation
Analyze and determine the eligibility and medical necessity of claims, coordinating with providers to ensure proper documentation and compliance with payer policies.
• Patient & Provider Communication
Serve as a liaison between patients, providers, and healthcare facilities to discuss diagnoses, treatment plans, and discharge processes, ensuring clarity and continuity of care.
• Pre-Authorization & Coverage Determination
Perform pre-service and retrospective clinical reviews using standardized criteria (e.g., MCG/IQ), ensuring proper benefit application and forwarding complex cases to medical directors when necessary.
• Regulatory Compliance & Documentation
Adhere to legal and regulatory standards (e.g., HIPAA, CMS) while accurately documenting assessments, findings, and outcomes to support quality assurance and care improvement initiatives.
Job Requirements:
• Active Philippine Registered Nurse (PHRN) License
Must hold a valid and active PHRN license.
• Clinical Experience
Minimum of 1 year hospital experience with direct patient care or employment as a Company/Clinic Nurse with verifiable Certificate of Employment (COE).
• Medical Knowledge & Analytical Skills
Strong understanding of clinical practices, diagnostic procedures, and treatment protocols. Ability to analyze medical records and assess claim eligibility based on medical necessity.
• Communication Proficiency
Excellent verbal and written communication skills in English; capable of clearly interacting with patients, providers, and internal teams.
• Technical and Regulatory Acumen
Familiarity with healthcare regulations and clinical guidelines (e.g., MCG, IQ, HIPAA). Ability to use medical management software and conduct detailed case reviews efficiently.