Precertification Nurse reviewer
EXL Service Philippines
Total years of experience :7 years, 3 Months
Responsible for precertification request medical review. The process entails that nurse reviewer ensures appropriate member eligibility and plan sponsor benefits and exclusions will be checked prior to applying medical review for the each precertification request. Medical review will utilize the applicable medical policy and industry standards. Responsible to collaborate/communicate with healthcare providers, members and medical directors to relay results of precertification medical review. Gives verbal notification via telephonic means for approval, medical director referral and offers peer-to-peer review options.
Responsible to collaborate with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources. Ensures medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting by utilizing the applicable medical policy and industry standards, accurately interpreting benefits and managed care products, and may steer members to appropriate providers, programs or community resources. Works with medical directors in interpreting appropriateness of care.
Serve as a staff nurse in the O.R, D.R, NICU complex which has a 10-room OR/DR complex that comprises of : one (1) Orthopedic Surgery Room, two (2) General Surgery Room, one (1) Cataract/Eye Surgery Room, one (1) Endoscopy/Colonoscopy Room, two (2)Obstetrical Surgery Room and two (2) Normal Delivery Rooms and 6 beds at the Recovery room, a breastfeeding room, a labor room with 4 beds and a very spacious Nursery for well babies, premature and sick babies.
I was mainly a full-time volunteer staff at the Operating Room area and was also an on-call reliever staff nurse position whenever a situation calls for. Serve as a circulating or scrub nurse in two (2) functional operation rooms and was also exposed in the 55-bed in all, medical-surgical ward, obstetrical-gynecology and pediatric ward performing as a Charge Nurse and as an Oral and Parenteral Medication Nurse. I was able to participate for the yearly surgical missions with Australian and German Interplast teams affiliated with the institution.
I was oriented to the different areas and departments of the institution, about its standard procedures and protocols of processes, but was primarily exposed to areas such as Neonatal lntensive Care Unit, Emergency Room, Private Rooms and the Medical-Surgical wards. On my On-call Staff Nurse status, I was then rotated at the private rooms, pediatric ward and the Medical-Surgical wards, with a primary nursing role, which includes being an Oral and Parenteral Medication Nurse.