PH REGISTERED NURSE

Job description
The Clinical UMR evaluates the appropriateness and necessity of medical treatment through the Utilization Management review process in order to promote quality, outcome-based medical care while providing world-class service to customers in an accurate, efficient and courteous manner.

Duties & Responsibilities

Primary Responsibilities
He/she works with groups of Employees (EEs), and Functional Heads in addition to individuals across a variety of tasks.
Maintains acceptable levels of performance including but not limited to attendance, adherence to protocols, customer courtesy, and all other productivity and efficiency targets and objectives.
Manages assigned workload within established performance standards.
Maintains confidentiality of all information, policies, and procedures as required by the Health Insurance Portability and Accountability Act (HIPAA) protocols.
Learns new methods and services as the job requires.
Advises supervisor of any potential problems as they become evident.
Attends meetings to achieve departmental goals and objectives.
Performs other duties as assigned or required.
Clinical Responsibilities

Performs Utilization Management (UM) reviews in accordance with U.S. State/Federal and other mandated regulations. Maintains compliance with regulatory changes affecting UM.
Performs UM reviews (prospective/concurrent/retrospective) for inpatient and outpatient services according to the prescribed standards and client requirements and/or policies.
Reviews UM requests for services against established clinical review criteria, referring cases not meeting criteria to a physician reviewer or prescribed escalation protocol.
Adheres to Department of Labor, State, and company UM timeframe requirements.
Coordinates physician reviewer referral as needed and follows up timely to obtain and deliver those results.
Tracks status of all UM in progress.
Releases UM determinations to claim stakeholders following client-established protocols.
Works closely with management team in the ongoing development and implementation of UM programs.
Certifies reviews that meet clinical review criteria/guidelines.
Adheres to quality standards and State UM guidelines.
Maintains all required UM review documentation in the UM software in a timely manner.
Serves as first level contact for customer complaint resolution.
Responds to inbound telephone calls pertaining to UM reviews in a timely manner, following client-established protocols.
Processes customer calls consistent with program specified strategies and customer satisfaction measurements to include but not limited to proper answering procedure, e.g. opening and closing remarks.
Education

Bachelor’s Degree in Nursing.
Eligibility

Must be a Philippine Registered Nurse (PHRN).
PHRN must have an active, current and unrestricted Philippine RN license.
Competencies

Knowledge of nursing principles, techniques, and procedures for the care of patients.
Knowledge of medical terminology, anatomy, physiology and concepts of disease
Makes sound clinical decisions in a timely manner
Skill in providing effective nursing care, assessing patient situations and taking effective courses of action
Must be proficient in utilizing relevant technologies and system applications commonly used in the work place.
Must be detail oriented and possess good organizational skills
Must have effective written and oral communication skills and be able to maintain confidentiality
Must have excellent interpersonal skills and team oriented to work in a high stress environment
Able to handle multiple tasks and shifting priorities Ability to work on projects and meet deadlines
Leadership Competencies
Process, Review, Analyze Medical Charts and correlate with Medical guideline appropriate for the patient’s condition.
Able to apply clinical/critical thinking on cases which need to be Referred to Physician Advisor.
Work Conditions

Must be willing to work rotational shifts with adherence to schedule, including evenings, weekends and overtime as necessary
Travel requirement as needed
Physical Demands:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this job, the employee is regularly required to sit, stand, walk, use hands to handle or feel, reach with hands and arms, stoop, kneel, crouch or crawl, talk or hear.
Lifting up to 25 pounds may be required
Specific vision abilities required by this job include close vision requirements due to computer work and distance vision to scan room during facilitation
Work Environment
The work environment characteristics described here are representative of those an employee may encounter while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Moderate noise.