Customer Service Rep- for Nurses ( clinical account) - QC, Quezon City

Accesses the appropriate coverage criteria. 

Performs Utilization Management review in accordance to federal and state mandated regulations, HUM URAC standards and client requirement and/or policies.

Maintains compliance with regulatory changes affecting Utilization Management.

Reviews the clinical information and treatment requests against established clinical review criteria, and determine if the criteria is met or not.

Documents review.

Protects and secures members Protected Health Information (PHI).

Responds to inbound calls pertaining to reviews in a timely manner, following client-established protocols.

Participates in discussion rounds with the Medical Director.

Arrives at a medical necessity decision conducting one of the following 3 things as an end result:

o Nurse approves requests that meet the criteria

o Nurse contractually denies requests excluded in member contract

o Nurse routes requests not meeting criteria to RMD or refers for Peer-to-peer

Notifies provider and member of decision through outbound calls