Clinical Program Nurse I

Responsible for auditing in-patient and/or surgical bills to promote excellence in medical bill review and process improvement. Medical Bill Review Processes inpatient and/or surgical bills by adhering to the given standard operating procedures (SOP) and turnaround time to complete the task. Performs bill review process by utilizing appropriate resources. Clarifies billing discrepancies to analyze and recommend appropriate reimbursement. Documents pertinent information in the system bill notes to support reimbursement determination. Performs reconsideration of bills, as per request, to ensure original bill processing determination is appropriate. Collaborates objectively with peer physicians to facilitate determination of reimbursement. Demonstrates knowledge and understanding of Broadspire medical department policies and procedures and ability to communicate same with internal/ external customers as necessary. Business Process Support Provides assistance to Business Process Associates and other concerned departments with regards to billing issues, inquiries on fee schedules and/or ground rules for a particular state. Inform appropriate process owner regarding issues related to calculation of reimbursement. Communicates effectively with persons involved in case management process as needed. Liaise with company attorneys to assist in possible litigated claims. Refers matters beyond limits of authority and expertise to immediate superior for direction. Upholds the Crawford Code of Conduct by protecting the confidentiality of information. Performs other related tasks as required or needed. Demonstrates knowledge and understanding of Broadspire medical department policies and procedures and ability to communicate same with internal/ external customers as necessary. Bachelor's degree in Nursing. Must have an active and in good standing without restriction Philippine RN license. Minimum of one (1) year diverse clinical experience or prior experience in medical bill review or claim/case review. Good communication skills. Proficient in word processing software applications. Analytical skills - Ability to perform basic bill review according to standard operating procedures (SOP). Maintains high degree of professionalism and confidentiality. Ability to multi-task, prioritize and manage time effectively. Interpersonal skills - Able to work independently and as a team member. Keen attention to details. Must complete continuing education requirements mandated the Professional Regulation Commission. Must complete courses as outlined by Crawford Educational Services.