Clinical Utilization Management Nurse Specialist (USRN)

Location: Vertis North, Quezon City

Work Setup: Onsite
Shift: US Day Shift
Employment Type: Full-time
Salary: Open, depending on experience and qualifications

Job Overview:

We are looking for a qualified Clinical Utilization Management Nurse Specialist (USRN) to review prior authorization and concurrent review requests, assess medical necessity, and ensure appropriate, timely, and cost-effective patient care within a US managed care environment.

Key Responsibilities:

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

• Coordinate with healthcare providers and internal teams for timely case resolution.

• Escalate cases requiring additional clinical assessment to Medical Directors.

• Support discharge planning and transfer authorization processes.

• Maintain accurate clinical documentation and case records.

• Provide guidance to healthcare providers and internal teams on utilization management procedures.

Qualifications:

• Bachelor of Science in Nursing (BSN) from an accredited nursing school.

• Active and unrestricted USRN license with NCLEX passed.

• Minimum of 1 year of clinical experience and 1 year of Utilization Management experience, OR at least 2 years of experience in Utilization Management, Prior Authorization, or Concurrent Review.

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

• Experience in a healthcare BPO or healthcare payer environment is preferred.

• Background in Utilization Review (UR) and Utilization Management (UM).

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

• Excellent analytical, clinical documentation, and communication skills.

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

Important Hiring Restrictions:

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

• Candidates previously employed by PSG Global, Majorel, or Aegis are also ineligible.

Prescreening Questions:

1. What is your highest educational attainment?

2. Do you have 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) or Utilization Management (UM)? Please provide details.

6. Do you have experience working 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 onsite in Vertis North, Quezon City, on a US day shift?

10. What was your last drawn salary?

11. What is your expected salary?