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USRN HIRING Competitive Salary.

Job Description:

  • Conduct Non-Clinical Research to Support Determinations
    • Determine that the case is assigned to the appropriate team and health plan for review (e.g., Medicare, Medicaid, Commercial, Dual Special Needs Plan)
    • Validate that cases/requests for services require additional research
    • Prioritize cases based on appropriate criteria (e.g., date of service, urgent, expedited)
    • Ensure compliance with applicable federal/state requirements and mandates (e.g., turnaround times, medical necessity)
  • Review Existing Clinical Documentation
    • Review/interpret clinical/medical rsubmittedittethe d from provider (e.g., office records, test results, prior operative reports)
    • Identify missing information from clinical/medical documentation, and request additional medical or clinical documentation as needed (e.g., LOI process, phone/fax)
    • Review and validate diagnostic/procedure/service codes to ensure their relevance and accuracy, as applicable (e.g., Prior Authorization List (PNL/EPAL), state grid, LCDs, NCDs)
    • Identify and then validate usage of non-standard codes, as necessary (e.g., generic codes)
    • Apply understanding of medical terminology and disease processes to interpret medical/clinical records o Make determinations per relevant protocols, as appropriate (e.g., approval, denial process, conduct further clinical or non-clinical research)
    • Review care coordinator assessments and clinical notes, as appropriate
  • Make Final Determinations Based on Clinical and Departmental Guidelines
    • Demonstrate understanding of business implications of clinical decisions to drive high quality of care
    • Understand and adhere to applicable legal/regulatory requirements (e.g., federal/state requirements, HIPAA, CMS, NCQA/URAC accreditation)
    • Ask critical questions to ensure member- and customer-centric approach to work
    • Identify and consider appropriate options to mitigate issues related to quality, safety or risk, and escalate to ensure optimal outcomes, as needed
    • Utilize evidence-based guidelines (e.g., medical necessity guidelines, practice standards, industry standards, best practices, and contractual requirements) to make clinical decisions, improve clinical outcomes and achieve business results
    • Identify and implement innovative approaches to the practice of nursing, in order to achieve or enhance quality outcomes
    • Use appropriate business metrics to optimize decisions and clinical outcomes
    • Prioritize work based on business algorithms and established work processes (e.g., assessments, case/claim loads, previous hospitalizations, acuity, morbidity rates, quality of care follow up)
  • Achieve and Maintain Established Productivity and Quality Goals
    • Meet/exceed established productivity goals
    • Adhere to relevant quality audit standards in performing reviews, making determinations and documenting recommendations
    • Manage/prioritize workload and adjust priorities to meet quality and productivity goals

80% Non-voice, 20% Voice (Outbound)


  • USRN (Mainland) with atleast 1 year hospital experience


  • PHP 34,000 – PHP 44,000 + PHP 11,600 Allowances (PHP 8,000 USRN Allowance)
  • HMO Upon Day 1
  • Free Shuttle Service
  • 10% Night Diferencial
  • 13th Month Pay
Job Overview
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