Clinical Program Nurse II

About the role

The Clinical Program Nurse II is responsible for reviewing medical information to determine the medical necessity and appropriateness of requested treatments. This role supports utilization management by applying established criteria and collaborating with peer physicians.

Key responsibilities

• Analyze medical information and apply utilization review criteria.
• Collaborate objectively with physicians to resolve cases.
• Document findings in internal and external communications.
• Follow standard operating procedures and turnaround times.
• Plan and organize individual caseload to meet review requirements.
• Refer complex matters to a supervisor and uphold confidentiality standards.

Required profile

• Bachelor's degree in Nursing.
• Active Philippine RN license in good standing.
• Minimum one year of diverse clinical experience or experience in medical bill/claim review.
• Strong communication, analytical, and interpersonal skills.
• Ability to multitask, prioritize, and maintain professionalism.
• Completion of continuing education mandated by the Professional Regulation Commission and Crawford Educational Services.

Required skills

• Word processing software applications.
• Medical claim review.

What we offer

• Opportunity to work within a multidisciplinary team.
• Professional development through required continuing education.