Manager, Utilization Review Nurse

5 days ago


กรงเทพมหานคร, Thailand Prudential Full time

Prudential's purpose is to help people get the most out of life. We will deliver our purpose by creating a culture in which diversity is celebrated and inclusion assured, for our colleagues, customers, and partners. We provide a platform for our people to do their best work and make an impact to the business, and in exchange, we support our people's career ambitions. We pledge to make Prudential a place where you can Connect, Grow and Succeed.

**Job Description**:
Medical Management & Utilization Review:

- Perform concurrent reviews and on-site for patients using Health Integrated behavioral health criteria

(Indication of admission and Length of Stay as a guideline, calculates the lengths of stay and continued-stay days for patients)

to ensure that the indication of admission and extended stays are medically justified, appropriateness, and documented in patient's medical records.
- Refer to the Utilization Review Physician for all cases that do not meet established guidelines for admission or continued stay.
- Identify problems related to the quality of patient care and refer such problems to Head of medical underwriting and claim COE
- Management of medical costs through timely concurrent review and retrospective review.
- Collect and summarize concurrent review report as assigned area every month and send all data to analyze by Medical analysis to be sent to the hospital network.
- Communicate with hospital networks to resolve instances of inappropriate utilization.

Qualifications:

- Bachelor’s degree, a specialization in nursing being a strong plus
- 3+ previous experience in UR nurse or claim administration
- Fluent in both written and spoken English
- Flexibility on the working hours will be expected
- Flexibility, adaptation, and a good mindset are key values for this role

Have excellence communication, interpersonal and analytical skills



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