Deskripsi Pekerjaan
Are you a healthcare professional with a sharp eye for detail and a passion for optimizing patient care? Sales Rain BPO Inc. is seeking a dedicated Utilization Management Coordinator to join our growing team in Cebu City. In this pivotal role, you will act as a bridge between healthcare providers and insurance entities, ensuring that patients receive the appropriate level of care at the right time.
As a Utilization Management Coordinator, you will analyze clinical documentation, evaluate patient records, and determine the medical necessity of services based on established clinical guidelines. This position is perfect for someone with a clinical background who wants to transition into an administrative, high-impact role within the BPO healthcare sector. We provide a collaborative environment, competitive compensation, and the opportunity to grow your career in a dynamic international setting.
Tanggung Jawab
- Review and analyze patient medical records to determine the medical necessity of requested procedures and services.
- Assess severity of illness and intensity of service using established clinical criteria (e.g., InterQual or Milliman).
- Communicate effectively with healthcare providers, clinical staff, and insurance representatives to resolve authorization discrepancies.
- Document all utilization review activities accurately within the electronic health record system.
- Ensure compliance with state, federal, and organizational regulations regarding patient data and privacy (HIPAA).
- Participate in peer-to-peer discussions to support medical necessity determinations when required.
- Maintain turnaround times for authorization requests to ensure seamless patient care transitions.
Kualifikasi
- Graduate of a Nursing (RN), Physical Therapy, Pharmacy, or other allied health professional degree.
- Active Professional License (PRC) is highly preferred.
- Minimum of 1-2 years of clinical experience in a hospital or clinical setting.
- Prior experience in Utilization Management, Case Management, or Medical Coding is a significant advantage.
- Strong knowledge of medical terminology, ICD-10, and CPT coding standards.
- Exceptional analytical skills with the ability to interpret complex clinical data.
- Proficient in Microsoft Office Suite and comfortable navigating multiple healthcare software platforms.
- Excellent written and verbal English communication skills.