Job Description: Clinical Utilization Management Nurse Specialist (USRN)

Job Title: Clinical Utilization Management Nurse Specialist (USRN)
Program: Healthcare – Hybrid Voice and Back-Office Operations
Location: Vertis North, Quezon City, Philippines
Work Setup: 100% Onsite
Shift Schedule: US Day Shift
Salary: Open, based on relevant experience, qualifications, and current or previous salary
Target Start Date: On or before December 15
Headcount: 6

Important Hiring Restrictions

• Former Teleperformance (TP) employees are not eligible for rehire, either directly or through a third party.

• Candidates previously employed by PSG Global, Majorel, or Aegis are also ineligible under the client's hiring restrictions.

Job Summary

We are seeking qualified US Registered Nurses (USRNs) to join our healthcare operations team as Clinical Utilization Management Nurse Specialists. The role involves reviewing prior authorization and concurrent review requests to determine medical necessity, appropriate levels of care, and alignment with established clinical guidelines within the US managed care environment.

The successful candidate will collaborate with healthcare providers, internal clinical teams, and Medical Directors to support timely case resolution, appropriate care coordination, and cost-effective healthcare delivery.

Key Responsibilities

• Review prior authorization and concurrent review requests to determine medical necessity and appropriate levels of care.

• Apply established clinical guidelines and utilization management criteria to evaluate healthcare services.

• Coordinate with healthcare providers and internal teams to facilitate timely case reviews and resolution.

• Escalate cases requiring higher-level clinical assessment or decision-making to Medical Directors.

• Support discharge planning, transfer authorization, and related workflows for concurrent review cases.

• Document clinical findings, review outcomes, and case decisions accurately in accordance with established standards.

• Guide healthcare providers and internal teams on utilization management procedures and requirements.

• Maintain compliance with applicable clinical review protocols, documentation standards, and operational guidelines.

• Support efficient case management while promoting appropriate, timely, and cost-effective care.

• Communicate clearly and professionally with healthcare providers and internal stakeholders.

Qualifications and Requirements

• Graduate of an accredited nursing school with a Bachelor of Science in Nursing (BSN).

• Active, unrestricted US Registered Nurse (USRN) license.

• NCLEX examination must have been passed.

• Must meet one of the following experience requirements:

  • At least 1 year of clinical experience in a hospital, clinic, or academic setting, plus 1 year of Utilization Management experience; or

  • At least 2 years of experience in Utilization Management, Prior Authorization, or Concurrent Review.

• Strong understanding of Medicare, Medicaid, and US managed care fundamentals.

• Experience in Utilization Review (UR) and Utilization Management (UM), particularly prior authorization or concurrent review.

• Healthcare BPO or healthcare payer experience.

• Familiarity with InterQual, MCG, or similar clinical decision-support criteria tools.

• Excellent analytical, clinical documentation, and communication skills.

• Willingness to work 100% onsite at Vertis North, Quezon City, on a US day shift.

Key Skills

• US Registered Nurse (USRN) License

• Utilization Management (UM)

• Utilization Review (UR)

• Prior Authorization

• Concurrent Review

• Medical Necessity Review

• Clinical Assessment

• Medicare and Medicaid

• US Managed Care

• InterQual and MCG Criteria

• Clinical Documentation

• Care Coordination

• Discharge Planning

• Transfer Authorization

• Case Review and Escalation

• Healthcare Provider Communication

• Clinical Decision Support

• Analytical and Critical-Thinking Skills

• Case Management

• Healthcare Compliance

• Attention to Detail

Work Arrangement

• Work location: Vertis North, Quezon City.

• Work setup: 100% onsite.

• Shift: US day shift.

• Target start: On or before December 15.

• Openings: 6.

• Compensation: Negotiable based on qualifications, experience, and client budget.

Candidates should have reasonable salary expectations aligned with the client's budget.

Pre-Screening Questions

1. What is your highest educational attainment?

2. Do you hold an active, unrestricted USRN license, and have you passed the NCLEX?

3. How many years of clinical experience do you have in a hospital, clinic, or academic setting?

4. How many years of experience do you have in Utilization Management, Prior Authorization, or Concurrent Review?

5. Do you have experience in Utilization Review (UR) and Utilization Management (UM)? Please provide details.

6. Have you worked in a healthcare BPO or healthcare payer environment?

7. How familiar are you with Medicare, Medicaid, and US managed care guidelines?

8. Have you used InterQual, MCG, or similar clinical decision-support tools?

9. Are you willing to work 100% onsite at Vertis North, Quezon City, on a US day shift?

10. What was your last-drawn salary?

11. What is your expected salary?

12. Have you previously been employed by Teleperformance, PSG Global, Majorel, or Aegis?

Recruitment Note: Verify USRN licensure, NCLEX completion, relevant clinical and utilization management experience, and employment eligibility against the client's hiring restrictions before proceeding.