Registered Nurse with 3 years clinical experience alabang (j001106)outsourced

Company Description
Outsourced.ph is a leading Philippines outsourcing company providing dedicated remote staff and offshore staffing services. We specialise in providing staff of the highest quality who will continue to exceed your expectations and provide benchmark offshore solutions to your business. With Outsourced you can scale your organisation quickly, easily and cost effectively with dedicated remote staff based in our modern offices in Manila.
Job Description
Company Background / Overview
The company is a management service organization. It provides healthcare management services to independent physician associations (IPAs). The company provides claims processing, credentialing, financial, provider relations, utilization management, case management, quality management and member services to IPAs.
Job Description
· Responsible for utilization management, utilization review, or concurrent review (telephonic inpatient care management).
· Perform reviews of current inpatient services and determine medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines (MCG) and benefit determination.
· Perform medical necessity and level of care reviews for requested medical services and refer to Medical Directors for review as appropriate depending on case development
Daily activities
· Performing care management activities to ensure that patients move through the continuum of care efficiently and safely
· Assesses and interprets patient needs and requirements
· Reviewing cases and analyzing clinical information in conjunction with Medical Directors to determine the appropriateness of hospitalization
· Performing Nurse to Physician interaction to acquire additional clinical information or discuss alternatives to current treatment plan
· Escalating cases to the Medical Director for case discussion or peer-to-peer intervention as appropriate
· Performing anticipatory discharge planning in accordance with the patient's benefits and available alternative resources
· Referring patients to disease management or case management programs
· Assisting with the development of treatment plans
· Documenting activities according to established standards
· Identifies solutions to non-standard requests and problems
· Solves moderately complex problems and / or conducts moderately complex analyses
· Works with minimal guidance; seeks guidance on only the most complex tasks
· Provides explanations and information to others on difficult issues
· Acts as a resource for others with less experience
· Works with less structured, more complex issues
· Update and review the case management and utilization management policies and procedures as needed
· Oversee the outpatient UM department
· Work on health plan initiated audits related to case management, utilization management, and related audits
· Submit and implement corrective action plans for issues identified during health plan audits
Working hours
8:30 AM to 5:30 PM (Pacific Time) California time
Qualifications
Would be Nice Features
· Current and unrestricted RN or LVN License in the State of California
· Clinical experience in an inpatient / acute setting
· Problem solving skills; the ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of action
· Excellent verbal and written communication skills; ability to speak clearly and concisely, conveying complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others
· Intermediate computer skills - Proficiency with Microsoft Word, web browsers, navigating in a Windows environment
· 1 year Utilization Management Inpatient experience
· Utilization Review experience
· Knowledge of or experience with Milliman Care Guidelines (MCG)
· Experience in discharge planning or chart review
· Experience in acute long term care, acute rehabilitation, or skilled nursing facilities
· A background that involves utilization review for an insurance company or in a managed care environment
Additional Information
By clicking on the "I'm Interested" button I hereby allow Outsourced Quality Assured Services, Inc. ("Outsourced") to store and collect my personal information for the purposes of employment application. As such, I agree and authorize Outsourced to collect, store, or continue to use my personal information for the above-stated purpose, and to retain my personal information for a period of 1 year, and for these purposes only.
outsourced

Muntinlupa City, Metro Manila
Permanent
Full-time