Registered Nurse (ONSITE)

- Job Summary -
A) Primary Responsibilities
1. He/she works with groups of Employees (EEs), and Functional Heads in addition to individuals across a variety of tasks.
2. 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.
3. Manages assigned workload within established performance standards.
4. Maintains confidentiality of all information, policies, and procedures as required by the Health Insurance Portability and Accountability Act (HIPAA) protocols.
5. Learns new methods and services as the job requires.
6. Advises supervisor of any potential problems as they become evident.
7. Attends meetings to achieve departmental goals and objectives.
8. Performs other duties as assigned or require
B) Clinical Responsibilities
1. Performs Utilization Management (UM) reviews in accordance with U.S. State/Federal and other mandated regulations.
2. Maintains compliance with regulatory changes affecting UM.
3. Performs UM reviews (prospective/concurrent/retrospective) for inpatient and outpatient services according to the prescribed standards and client requirements and/or policies.
4. Reviews UM requests for services against established clinical review criteria, referring cases not meeting criteria to a physician reviewer or prescribed escalation protocol.
5. Adheres to Department of Labor, State, and company UM timeframe requirements.
6. Coordinates physician reviewer referral as needed and follows up timely to obtain and deliver those results.
7. Tracks status of all UM in progress.
8. Releases UM determinations to claim stakeholders following client-established protocols.
9. Works closely with management team in the ongoing development and implementation of UM programs.
10. Certifies reviews that meet clinical review criteria/guidelines.
11. Adheres to quality standards and State UM guidelines.
12. Maintains all required UM review documentation in the UM software in a timely manner.
13. Serves as first level contact for customer complaint resolution.
14. Responds to inbound telephone calls pertaining to UM reviews in a timely manner, following client-established protocols.
15. 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.
- Job Requirements -
Must be a Philippine Registered Nurse (PHRN)