DE033635-Health Clinical Services Senior Analyst

• ONLY THOSE APPLICANTS WHO ALREADY HAVE THE RIGHT TO LIVE AND WORK IN THIS COUNTRY ARE ELIGIBLE TO APPLY FOR THIS ROLE--- POSITION TITLE: Health Clinical Services Senior Analyst WORK SETUP: Hybrid RESPONSIBILITIES:
• Conduct UM pre-service, concurrent, retrospective, out of network, and appropriateness of treatment setting. Reviews service requests to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.
• Utilize client specific criteria sets (e.g., Milliman or Inter

Qual), applicable client specific medical policy and client clinical guidelines for decision making to either approve or summarize and route to Client's nursing reviewer and/or Client's medical staff for review.

• Accurately routes cases to client medical staff for further review when a service or admission does not meet medical necessity, place of service, or benefit criteria.
• Responsible for conducting medical management review activities which require the review of clinical information against client specific criteria as

note

d above but excludes denial determinations.

• Ensure member access to medically necessary, quality healthcare in a cost-effective setting according to contract. Consult with clinical reviewers and/or U.S.-licensed medical directors to ensure medically appropriate, high-quality, cost-effective care throughout the medical management process.
• Collaborate with providers to assess members, needs for early identification and proactive planning for discharge planning. Facilitate member care transition through the healthcare continuum and refer treatment plans/plan of care to clinical reviewers as required. OTHERS: Project Shift Schedule: Night Shift Project Rest Day: Weekends Off Project/Team Location: Quezon Cyberpark Tower 3

SKILL AND QUALIFICATIONS

• Holds current and unrestricted US Registered Nurse license
• 3 months clinical experience (480 hours of working experience as a RN)
• Work experience as an active RN license and providing direct patient care
• Clinical setting includes inpatient hospital, outpatient hospital or community clinic
• No state license required (doability will be revisited if there's a specific state of RN license needed)
• Bachelor of Science Nursing (BSN) degree