USRN Hiring Manila

Position Title

USRN Hiring Manila Shift

Job Description

Responsible for collaborating with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources. Ensures medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting by utilizing the applicable medical policy and clinical guidelines, accurately interpreting benefits, and managed care products, and steering members to appropriate providers, programs or community resources. Works with medical directors in interpreting appropriateness of care and accurate claims payment. May also manage appeals for services denied.

Responsibilities

• Conducts pre‑certification, continued stay review, care coordination, or discharge pla...