Medical Review Nurse

Essential Job Duties and Responsibilities:

Job Title: Medical Review Nurse

Set-up: Work Onsite (Ortigas, Pasig)

Schedule: Monday- Friday (Fixed Weekends Off) 9AM - 6PM Manila Time

Overall Purpose of the Job:

The Medical Review Nurse will be responsible for reviewing and processing incoming medical reports for beneficiaries. They will ascertain whether a case can be closed if care is complete or will issue an authorisation to a network provider when follow up care is required.
The Medical Review Nurse will communicate with beneficiaries, providers, and points of contact via email when needed. If additional intervention is required, the Medical Review Nurse will appropriately task other teams within the case.

Key Responsibilities:

• Process medical reports as follows:
  • Review medical reports to check for accuracy and completeness, raising any quality issues identified as needed.
  • Close cases where no further care is required
  • Perform benefit reviews when further care is required, issuing authorisation letters or denials as appropriate
  • Reallocate cases to the relevant team for regional expertise as required
  • Email beneficiaries to inform them of non-urgent advice for follow up care in the future
  • Send updates to the client when contractually required
• Escalate complex cases to the Medical Review Nurse Team Leader or Senior Medical Review Nurse
• Escalate any concerns/complaints to the Medical Review Nurse Team Leader
• Ensure consent and confidentiality is maintained for all medical information

Qualifications:

• Active Philippines Registered Nurse License (valid for at least 12 months upon application)
• Graduate of Bachelor of Science in Nursing
• At least 2 years of clinical experience; Broad nursing experience is preferred
• Prior experience in utilization management, case management or reviewing of medical reporting is also desirable.
• Excellent written and oral English Language
• Computer literate

Description:

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