Utilization Management Nurse
Tenet Global Business Centre, Inc.
Taguig, PH
2d ago
source : Bossjob
  • Performs pre-service authorization reviews to obtain payment authorization for both inpatient and outpatient services. Succinctly abstracts fact based clinical information to support pre-authorization utilizing applicable nationally recognized and payer-specific criteria.
  • Communicates timely the clinical information supporting the medical necessity of an ordered test / treatment / procedure / surgery as applicable to the patient’s health plan and documents the outcome of the task.
  • Performs the following activities to support the effective operation of the organization’s quality management system.
  • Participation in quality control audit process; participation in department projects and activities to improve overall company and client scorecard metrics.
  • provides feedback regarding improvement opportunities for workflow & / or procedures; and the contributes to successful implementation of all the above.

  • Demonstrates proficiency in the use of multiple electronic tools required by both the company and its clients.
  • Collaborate with and engage internal and external customers, such as facility patient access and physician offices, in opportunities for prevention of future disputes;
  • identifies potential process gaps and recommends sound solutions to CAS leadership.

  • Must possess an active nursing license (Registered or Practical / Vocational). Licensed Nurse Practitioner / Registered Nurse.
  • Experience in Utilization Review, Utilization Management, Case Management, Pre-Authorization in a payer or acute care setting;
  • preferably medical-surgical or critical care / ED.

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