Clinical Program Nurse III

Responsible for providing proactive case management services by assessing existing medical records.

• Case Management Services
  • Analyzes and reviews case records, evaluates client's medical status, and defines their needs and problems.
  • Provides opinions regarding case costs, treatment plan, outcome and problem areas, and makes recommendation to facilitate rehabilitation goals and return to work.
  • Utilizes experience and medical resources to interpret medical records and test results, and provide appropriate assessments accordingly.
  • Reviews cases with immediate superior monthly to evaluate files and obtain directions.
  • Performs job site evaluations/summaries to facilitate case management process.
  • Demonstrates knowledge and understanding of Broadspire medical department policies and procedures and ability to communicate same with internal/ external customers as necessary
• Client Relations
  • Establishes professional working relationship with internal and external clients by timely return to work.
  • Maintains contact with all parties involved on case to appraise them of case activity, case direction, or receive authorization for services.
  • Demonstrates knowledge and understanding of Broadspire medical department policies and procedures and ability to communicate same with internal/ external customers as necessary
• Business Process Support
  • Performs peer reviews and independent medical examination.
  • Meets monthly production and quality assessment (QA) requirements.
  • Deals with problem resolution independently by using appropriate research and resources.
  • Refers matters beyond limits of authority and expertise to immediate superior for direction.
  • Upholds the Crawford Code of Conduct by protecting the confidentiality of information.
  • Performs other related tasks as required or needed.
  • Demonstrates knowledge and understanding of Broadspire medical department policies and procedures and ability to communicate same with internal/ external customers as necessary

• Bachelor's degree in Nursing.
• Must have an active and in good standing without restriction Philippine RN license; Has an active and in good standing without restriction US RN license from any mainland state.
• Minimum of two (2) years diverse clinical experience or prior experience in Medical Bill Review.
• Excellent verbal communication skills and customer orientation.
• Proficient in word processing software applications.
• Analytical skills - Ability to perform basic and complex bill review according to standard operating procedures (SOP).
• Ability to deliver excellent customer service.
• Active listening and phone handling skills.
• Critical thinking skills - Ability to make judgements and recommendations.
• Maintains high degree of professionalism and confidentiality.
• Ability to multi-task, prioritize and manage time effectively.
• Interpersonal skills - Able to work independently and as a team member.
• Keen attention to details.