Nezda Technologies Inc. is currently hiring for Clinical Nurse Case Manager – USRN.
Salary: P 50,000 – P 68,000 (with Perks and benefits).
Work Set up: Work From Home
Qualifications:
Active and Non-Active USRN License. With at least 1 Year Clinical or Hospital Experience. USRN with RN License.
Job Description:
We are in partnership to multiple companies for this position, so you have an option and which company fits you best. Please take note that this is a direct employment with no bond.
Primary Responsibility: Conduct UM pre-service, concurrent, retrospective, out of network, and appropriateness of treatment setting. Reviews service requests to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits and contracts. Utilize client specific criteria sets (e.g., Milliman or InterQual), applicable client specific medical policy and client clinical guidelines for decision making to either approve or summarize and route to Client’s nursing reviewer and/or Client’s medical staff for review. Responsible for conducting medical management review activities that require the review of clinical information against client-specific criteria as noted above but excludes denial determinations. Ensure member access to medically necessary, quality healthcare in a cost-effective setting according to the contract. Consult with clinical reviewers and/or U.S. licensed medical directors to ensure medically appropriate, high-quality, cost-effective care throughout the medical management process.
