Health Clinical Services Analyst

Gratitude Inc

771 Views

19 hours ago

0-3 Year(s)

Manila

Job Description

Key Skills

USRN USRN License

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Position: Health Clinical Services Senior Analyst

Location: Taguig

Salary: Open Budget [Based on Experience]

**JOB DESCRIPTION**

• Conduct UM pre-service, concurrent, retrospective, out of network, and appropriateness of treatment setting.

• Reviews service requests to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits and contracts.

• Utilize client-specific criteria sets (e.g., Milliman or InterQual), applicable client-specific medical policy and client clinical guidelines for decision-making to either approve or summarize and route to Client's nursing reviewer and/or Client's medical staff for review.

• Accurately routes cases to client medical staff for further review when a service or admission does not meet medical necessity, place of service, or benefits criteria.

• Responsible for conducting medical management review activities that require the review of clinical information against client-specific criteria as noted above but excludes denial determinations.

**JOB QUALIFICATIONS**

• Graduate of Bachelor of Science in Nursing (BSN)

• Must have at least 3 months work experience as a Registered Nurse in a clinical setting

• Must have an active USRN License

• Holds current and unrestricted US Registered Nurse license (state-specific RN licensure)

• Must be willing to work on a shifting schedule including graveyard shift

• Must be willing to report onsite during the training period for 3 months. Work from home after training but must be amenable to report onsite based on client/project mandate

Role

NON-BPO

Timings

Flexible (Permanent)

Industry

NON-BPO

Work Mode

Process

Non-Voice

Functional Area

NON-BPO

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