Offer description

Must have an Active PRC Nursing License.

At least 1 year of cumulative clinical bedside care experience (hospital, clinic, healthcare facility, etc.) or business process experience (healthcare data management), or any combination which would provide an equivalent background.

Experience with daily operations in a clinical, managed care, hospital care setting including working with provider systems and medical providers is an advantage.

Prior Utilization Management or Prior Authorization Clinical Experience is an advantage, but not required.

Role requires strong oral, written, and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.

Must have a minimum of 25mbps wired internet speed.

Responsibilities:

Review service requests to ensure compliance with applicable criteria, medical policy, member eligibility, benefits, and contracts.

Route cases to client medical staff for further review when a service or admission does not meet medical necessity, place of service, or benefits criteria.

Work with clinical reviewers and medical directors in interpreting appropriateness of care and conducting claims reviews utilizing the member’s benefit contract and health plan guidelines.

Process incoming requests, collection of information needed for review from providers.

Determine contract and benefit eligibility, obtain intake demographic information from callers and/or faxes.

Requirements

• Minimum education level: Bachelor´s Degree
• 1 year of experience
• Availability to travel: No
• Availability of change of residence: No

More than 30 days ago

About Global Headstart Specialist, Inc.

Global Headstart Specialist, Inc. provides call center jobs and other local employment to Filipinos in Metro Manila and across the Philippines. We specialize in providing industry-leading human resources (HR) solutions including, but not limited to: sourcing and recruitment, training & development and executive search. Our team is comprised of seasoned HR professionals and senior executives locally and abroad who boast of years of business experience. Global Headstart Specialist, Inc. understa...

Global Headstart Specialist, Inc. provides call center jobs and other local employment to Filipinos in Metro Manila and across the Philippines. We specialize in providing industry-leading human resources (HR) solutions including, but not limited to: sourcing and recruitment, training & development and executive search. Our team is comprised of seasoned HR professionals and senior executives locally and abroad who boast of years of business experience. Global Headstart Specialist, Inc. understands the growing human resource needs of contact centers and various business industries. We guarantee to alleviate our clients’ HR demands and helping them achieve their goals. We are thoroughly dedicated to working with our clients to exceed their expectations and provide the best quality of applicants and service. To ensure this we customize our qualification processes to fit the client’s specific needs, determined to uphold confidentiality and professionalism. A proven track record, knowledgeable staff, state-of-the-art technology and a personal touch define the Headstart advantage.

Our Vision and Mission

At the core of the HEAD​START​ way is our vision to be the number one job provider in the Philippines and in Asia. ​
In order to achieve this, Global Headstart Specialist, Inc. will serve as the link for prospective employers and potential employees, and strive to educate and equip job seekers with the necessary skills and values to excel in their jobs.