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 (SOP) and turnaround times.
• Plan and organize individual caseload to meet review requirements.
• Communicate effectively with all parties involved in the review process.
• Escalate matters beyond authority to a supervisor.
• Uphold confidentiality and the Crawford Code of Conduct.

Required profile

• Bachelor's degree in Nursing.
• Active Philippine RN license in good standing.
• Minimum one (1) year of diverse clinical experience or prior experience in medical bill or claim review.
• Strong communication, analytical, and interpersonal abilities.
• Professionalism, confidentiality, and attention to detail.
• Ability to multi‑task, prioritize, and manage time effectively.
• Completion of continuing education mandated by the Professional Regulation Commission and Crawford Educational Services.

Required skills

• Proficiency with word processing software applications.