NurseMedical InforSpecialistIV
Medata
Date: 8 hours ago
City: Mandaluyong City
Contract type: Full time
Position Overview
The Nurse Utilization and Clinical Advisor Services Analyst IV is responsible for applying clinical expertise to drive improvements in healthcare resource utilization, cost, and quality. This role focuses on analyzing healthcare cases and claims, providing guidance on the appropriateness of care, and coordinating with clients and clinical peer reviewers to support healthcare delivery standards.
Key Responsibilities
The Nurse Utilization and Clinical Advisor Services Analyst IV is responsible for applying clinical expertise to drive improvements in healthcare resource utilization, cost, and quality. This role focuses on analyzing healthcare cases and claims, providing guidance on the appropriateness of care, and coordinating with clients and clinical peer reviewers to support healthcare delivery standards.
Key Responsibilities
- Apply clinical judgment in the adjudication of cases and claims.
- Review requests for denial reconsideration and appeals.
- Manually price and evaluate claims, including drugs and medical supplies, for care appropriateness and coverage.
- Provide input directly to clients in alignment with program policies and procedures.
- Collaborate with clinical peer reviewers to resolve cases and claims.
- Perform additional duties as assigned and ensure compliance with all company policies and standards.
- Education: Bachelor’s degree or equivalent experience in a relevant field.
- Licensure: Active Registered Nurse (RN) license in good standing.
- Experience: Prior experience in a healthcare or medical services role, preferably involving claims or case review, is required.
- Skills:
- Strong analytical skills to assess and resolve straightforward problems.
- Ability to interpret program policies and procedures effectively.
- Proficiency in explaining complex information to others in clear, straightforward situations.
How to apply
To apply for this job you need to authorize on our website. If you don't have an account yet, please register.
Post a resumeSimilar jobs
Senior Electrical Engineer (Power Systems)
Jacobs,
Mandaluyong City
3 hours ago
At Jacobs, we're challenging today to reinvent tomorrow by solving the world's most critical problems for thriving cities, resilient environments, mission-critical outcomes, operational advancement, scientific discovery and cutting-edge manufacturing, turning abstract ideas into realities that transform the world for good.Your impactDesign large-scale, transmission-connected simple cycle or combined cycle power plants.Collaborate with U.S.-based design teams to develop detailed design documentation.Provide engineering...
IT Service Desk Analyst (AU Aged Care, Hybrid)
ConnectOS,
Mandaluyong City
2 days ago
DescriptionSalary: P50,000 - P80,000 (Monthly Package)Schedule: Monday to Friday (6:00am to 3:00pm PHT)What are we looking for?Skills RequiredMinimum of ITIL foundations certification, higher levels are desirable.Minimum 3 years experience in a Service Desk, IT support role or equivalent. Microsoft Certified Professional (MCP) or Fundamentals certification. Nice To HaveG-Suite / Google workspace. Office 365. Printer management and administration. Microsoft Server. Microsoft...
Sales Training Officer
BDO Unibank,
Mandaluyong City
3 days ago
Job MandatePrimarily responsible for design, implementation, monitoring and evaluation of training programs and initiatives.Duties And ResponsibilitiesA Sales Training Officer will be responsible for one or a combination of these duties: Participate in concept meetings with training program proponents/requesting units. Design and development of content of training programs catering to new hires and regular employees Perform correspondence and coordinate execution of...
