Job Title: Medical Benefits Review Nurse
Location: Pasig, City
Start Date: November 5, 2024
Basic Function:
The Manila-based Medical Benefits Review Nurse is responsible for reviewing the appropriateness of health care services requested and their coverage under the health insurance policies of participating Program Carriers providing health insurance.
Essential Function:
Core Activities:

• Conduct care management review processes that are consistent with client Carrier’s policies and industry standards.
• Conduct all care management reviews according to accepted and established criteria, as well as other approved guidelines and medical policies.
• Ensure quality and efficiency in the delivery of care management services.
• Respect the member’s right to privacy, sharing only relevant information to the member’s care and within the framework of application laws.
• Practice within the scope of ethical principles.
• Participate in collaborative interventions which focus, facilitate, and maximize the Civilian’s health care outcomes.
• Develop and sustain positive working relationships with internal and external customers.
• Utilize outcome data to improve ongoing care management services.
• Other duties as assigned or requested.

Primary Internal Interaction:

• Ensure the coverage requests are promptly directed to the relevant clinical staff in assignment with established practices, workflow process and departmental requirement.
• Engage in team meetings, discussion and contribute insights actively.
• Collaborate, cooperate, and provide support to the team, working together to exceed team goals.
• Reviews documentation and evaluates potential quality of care issues based on clinical policies and benefit determinations.
• Considers all documented system information as well as any additional records/data presented to develop a recommendation.
• Data gathering requires navigation through multiple system application.
• Condenses complex information into a clear and precise clinical picture while working independently.
• Pro-actively and consistently applies the regulatory and accreditation standards to assure that activities are reviewed and processed with guidelines.

Primary External Interactions

• Collaborate with colleagues to contact providers of record, vendors, or internal departments to obtain additional information.
• Evaluates documentation/information to determine compliance with clinical guidelines and insurance policy benefits.
• Accurately apply review requirements to assure case is reviewed by a practitioner with appropriate clinical expertise when needed.
• Command a comprehensive knowledge of complex clinical criteria, Carrier benefit plans and policies, and other processes which are required to support the review of the clinical documentation and information.

Occupational Health & Safety

• Comply with OH&S requirements as an employee
• Support the execution of an organizational culture that is committed to OH&S across all areas of responsibility.
• Support HR/GA manager and local leadership to successfully apply OH&S policy and procedures to ensure compliance with Intl.SOS and regulatory requirements for OH&S at all times.
• Monitor the OH&S Management System compliance and performance for area of responsibility and follow up on OH&S action items.
• Act as a role model by demonstrating safe work behaviours.
• Actively participate in the implementation of the OH&S inspections and audits relating to Office OH&S including corrective actions.
• Maintain current knowledge of OH&S matters.

Skills and Profile:
Technical Skills:

• Strong customer service skills to coordinate service delivery including attention to customers, sensitivity to issues, proactive identification, and resolution of issues to promote positive outcomes for members.
• Computer literacy in order to navigate through internal/external computer systems, including Excel and Microsoft Word.
• Ability to effectively participate in a multi-disciplinary team including internal and external participants.
• Familiarity with basic medical terminology and concepts used in care management.
• Excellent data entry skills and attention to detail and accuracy.
• Good MS Office Suite skills.
• Knowledge of mainframe, web-based applicants, and populating data into MS Access data bases and other systems/applications.

Process Specific Skills:

• Maintain an outstanding level of customer service throughout all points of customer contact.
• Ensure the appropriate clinical staff receives the call, or written request in a timely manner and according to established practices, workflow processes, and department needs.
• Accurately apply specific guidelines, policies, and procedures as authorized by the clinical review areas and in coordination.
• Strong interpersonal, verbal and written communication skills; ability to express moderate to complex issues to individuals, groups, internal and external contacts, and write clear, concise, and grammatically correct materials.
• Strong organizational, research, and analytical skills.
• Demonstrate decision making and problem-solving skills.
• Demonstrate the ability to effectively deal with escalated situations

Soft Skills:

• Positive, professional, service-oriented behaviour.
• Demonstrated time management skills.
• Abilities to effectively apply and demonstrate, workflow instructions and successfully meet turn-around-time expectations.
• Effective communication, telephonic and organization skills.
• Clear written and verbal communication skills.

Educational Requirements:

• Active Philippines and USA Registered Nurse License (valid for at least 12 months upon application)
• Graduate of Bachelor of Science in Nursing

Work Experience:

• At least 5 years of clinical experience
• Medical Benefit Review experience in a BPO set-up is a plus.

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Job Type: Full-time