Clinical Utilization Management Reviewer (Clinical UMR)

Duties & Responsibilities

• Primary Responsibilities
  • He/she works with groups of Employees (EEs), and Functional Heads in addition to individuals across a variety of tasks.
  • Maintains acceptable levels of performance including but not limited to attendance, adherence to protocols, customer courtesy, and all other productivity and efficiency targets and objectives.
  • Manages assigned workload within established performance standards.
  • Maintains confidentiality of all information, policies, and procedures as required by the Health Insurance Portability and Accountability Act (HIPAA) protocols.
  • Learns new methods and services as the job requires.
  • Advises supervisor of any potential problems as they become evident.
  • Attends meetings to achieve departmental goals and objectives.
  • Performs other duties as assigned or required
• Clinical Responsibilities
  • Performs Utilization Management (UM) reviews in accordance with U.S. State/Federal and other mandated regulations. Maintains compliance with regulatory changes affecting UM.
  • Performs UM reviews (prospective/concurrent/retrospective) for inpatient and outpatient services according to the prescribed standards and client requirements and/or policies.
  • Reviews UM requests for services against established clinical review criteria, referring cases not meeting criteria to a physician reviewer or prescribed escalation protocol.
  • Adheres to Department of Labor, State, and company UM timeframe requirements.
  • Coordinates physician reviewer referral as needed and follows up timely to obtain and deliver those results.
  • Tracks status of all UM in progress.
  • Releases UM determinations to claim stakeholders following client-established protocols.
  • Works closely with management team in the ongoing development and implementation of UM programs.
  • Certifies reviews that meet clinical review criteria/guidelines.
  • Adheres to quality standards and State UM guidelines.
  • Maintains all required UM review documentation in the UM software in a timely manner.
  • Serves as first level contact for customer complaint resolution.
  • Responds to inbound telephone calls pertaining to UM reviews in a timely manner, following client-established protocols.
  • Processes customer calls consistent with program specified strategies and customer satisfaction measurements to include but not limited to proper answering procedure, e.g. opening and closing remarks.
• Reports
  • As may be required by his/her superiors to participate in the review, preparation, and submission of operations-related reports
• Miscellaneous
  • Ensures compliance to company rules and regulations, which shall include but not limited to the Employee Code of Discipline, the policies on Quality Management System (QMS), Information Security Management System (ISMS), Environment Health & Safety (EHS), and Environmental Management System (EMS); and other duties and responsibilities prescribed for all AMDATEX employees.
  • Ensures compliance of all Non-Conformity Corrective Action Preventive Action Concessions (NCAPACs) and all other audit findings within the prescribed period.
  • Reports security incidents and/or any identified security weaknesses.
  • Performs other tasks that may be assigned from time to time.
• NURSE LICENSURE JURISDICTION NOTICE:
  • A person shall be deemed to be practicing nursing when he/she singly or in collaboration with another, initiates and performs nursing services to individuals, families and communities in any health care setting. It includes, but not limited to, nursing care during conception, labor, delivery, infancy, childhood, toddler, pre-school, school age, adolescence, adulthood and old age. As independent practitioners, nurses are primarily responsible for the promotion of health and prevention of illness. As members of the health team, nurses shall collaborate with other health care providers for the curative, preventive, and rehabilitative aspects of suffering, and when recovery is not possible, towards a peaceful death.
  • In the practice of nursing in all settings, the nurse is duty-bound to observe the Code of Ethics for nurses and uphold the standards of safe nursing practice
  • Nurses with revoked or suspended licenses are not eligible for the Nurse Agent position until after a new license is issued him/her
  • Revocation of certificate is granted by the Nursing Board for reasons of equity and justice and when the cause for revocation has disappeared or has been cured and corrected (after the expiration of a maximum of 4 years from effective date of revocation), upon proper application therefore and payment of the required fees
  • All lost, destroyed, or mutilated certificate needs to be applied for a replacement with the Philippine Regulation Commission otherwise employment application with ADEC is not honored
  • A fine of not less than Fifty thousand pesos (P50,000.00) nor more than One hundred thousand pesos (P100,000.00) or imprisonment of not less than one (1) year nor more than six (6) years, or both, upon the discretion of the court, shall be imposed upon:
    • any person practicing nursing in the Philippines without a certificate of registration/professional license and professional identification card or special temporary permit or without having been declared exempt from examination in accordance with the provision of the Philippine Nursing Act of 2002;
    • uses as his/her own certificates of registration/professional license and professional identification card or special temporary permit of another;
    • uses as invalid certificate of registration/professional license, a suspended or revoked certificate of registration/professional license, or an expired or cancelled special/temporary permit;
    • gives any false evidence to the Board in order to obtain a certificate of registration/professional license, a professional identification card or special permit;
    • falsely poses or advertises as a registered and licensed nurse or uses any other means that tend to convey the impression that he/she is a registered and licensed nurse;
    • appends B.S.N./R.N. (Bachelor of Science in Nursing/Registered Nurse) or any similar appendage to his/her name without having been conferred said degree or registration;
    • as a registered and licensed nurse, abets or assist the illegal practice of a person who is not lawfully qualified to practice nursing;
    • any person or employer of nurses who violate the minimum base pay of nurses and the incentives and benefits that should be accorded them.
  • A special/temporary permit may be issued by the Board to the following persons subject to the approval of the Commission and upon payment of the prescribed fees:
    • Licensed nurses from foreign countries/state whose service are either for a fee or free if they are internationally well-known specialist or outstanding experts in any branch or specialty of nursing;
    • Licensed nurses from foreign countries/state on medical mission whose services shall be free in a particular hospital, center or clinic; and
    • Licensed nurses from foreign countries/state employed by schools/ in a branch or specialty of nursing; Provided, however, That the special/temporary permit shall be effective only for the duration of the project, medical mission or employment contact.

Job Requirements

• Education
  • Bachelor’s Degree in Nursing.
• Experience
  • Must have relevant years of clinical BPO experience in any of or similar domains of Utilization Management, Case Management, Disease Management, Wellness, Medical Coding and Billing, Pharmacy Benefits Management, Claims Management in any of the U.S. industry sectors of Workers’ Compensation; Commercial Managed Care; Health, Disability, Life, Property and Casualty Insurance; Accountable Care Organizations (ACO’s) or any other sector wherein the work performed is related to the use of clinical knowledge and skills.
  • Position level and salary will depend on years of relevant experience
    • Level I – one (1) year or less
    • Level II – one (1) year and one (1) month to three (3) years
    • Level III – three (3) years and one (1) month or more
• Eligibility
  • For NURSES:
    • Must be a Philippine Registered Nurse (PHRN), and a US Registered Nurse (USRN) when required in the program he/she is assigned to;
    • Philippine-based Nurse must have an active, current and unrestricted Philippine RN license; and an active, current, and unrestricted US RN license when required in the program he/she is assigned to.
    • U.S.-based Nurse must have and an active, current, and unrestricted US RN license
  • For OTHER HEALTH SCIENCES PROFESSIONAL:
    • Must be a Philippine Registered Professional in their respective field, and a US Registered Professional in their respective field when required in the program he/she is assigned to.
    • Must have an active, current and unrestricted relevant Philippine Professional license issued by the Professional Regulation Commission (PRC); and an active, current, and unrestricted additional Professional License or Certificate in their respective domain expertise such as Certified Medical Coders, or similar, when required in the program he/she is assigned to.
• Competencies
  • Knowledge of nursing principles, techniques, and procedures for the care of patients.
  • Knowledge of medical terminology, anatomy, physiology and concepts of disease
  • Makes sound clinical decisions in a timely manner
  • Skill in providing effective nursing care, assessing patient situations and taking effective courses of action
  • Must be proficient in utilizing relevant technologies and system applications commonly used in the work place.
  • Must be detail oriented and possess good organizational skills
  • Must have effective written and oral communication skills and be able to maintain confidentiality
  • Must have excellent interpersonal skills and team oriented to work in a high stress environment
  • Able to handle multiple tasks and shifting priorities Ability to work on projects and meet deadlines
  • Leadership Competencies
    • Process, Review, Analyze Medical Charts and correlate with Medical guideline appropriate for the patient’s condition.
    • Able to apply clinical/critical thinking on cases which need to be Referred to Physician Advisor.
  • ADEC Innovations Values & Core Competencies
    • Commitment to the Company’s vision & mission
    • Customer Focus, Excellence, Respect, Teamwork, Integrity, Commitment (CERTIC)
    • Excels at operating in a fast-paced and diverse environment
    • Demonstrated high professional and ethical standards

Job Factors

• Scope of Impact
  • Local geographic reach ADEC Healthcare
• Internal Contacts
  • Middle Management
  • Non-Management Staff
• External Contacts
  • Clients
• Work Conditions
  • Must be willing to work rotational shifts with adherence to schedule, including evenings, weekends and overtime as necessary
  • Travel requirement as needed
  • Physical Demands:
    • The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
    • While performing the duties of this job, the employee is regularly required to sit, stand, walk, use hands to handle or feel, reach with hands and arms, stoop, kneel, crouch or crawl, talk or hear.
    • Lifting up to 25 pounds may be required
    • Specific vision abilities required by this job include close vision requirements due to computer work and distance vision to scan room during facilitation
  • Work Environment
    • The work environment characteristics described here are representative of those an employee may encounter while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
    • Moderate noise.

Confidentiality & Non-Disclosure Agreement Corollary to the Position

• By the nature of your job, the responsibilities reposed upon you in a position of trust; as well as the Company, Employee, and Client information that come to your knowledge and are under your care; you agree and bind yourself with the Confidentiality & Non-Disclosure policy set forth by the Company. Any violation of this agreement as a result of your breach through mishandling of information and abuse of discretion on privileged information, will be subject to disciplinary action including and up to termination of employment.