Clinical Utilization Management Nurse Specialist (USRN)

JOB OVERVIEW

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‎We are looking for a qualified US Registered Nurse (USRN) with experience in Utilization Management (UM) or Utilization Review (UR).

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‎The successful candidate will use their clinical knowledge and expertise to review prior authorization and concurrent review requests, assess medical necessity, and determine the appropriate level of care based on established clinical guidelines.

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‎This role supports a US managed care environment, ensuring members receive appropriate, timely, and cost-effective healthcare services while coordinating with healthcare providers and internal teams.

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‎KEY RESPONSIBILITIES

‎Review prior authorization and concurrent review requests to determine medical necessity and the appropriate level of care.

‎Coordinate with healthcare providers and internal teams to ensure timely case resolution.

‎Escalate cases requiring additional clinical assessment or approval to Medical Directors.

‎Support discharge planning and transfer authorization processes for concurrent review cases.

‎Accurately document clinical findings, assessments, and case decisions in accordance with established standards.

‎Provide guidance to healthcare providers and internal teams regarding Utilization Management processes.

‎QUALIFICATIONS

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

‎Must have an active and unrestricted US Registered Nurse (USRN) license.

‎Must have passed the NCLEX.

‎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.

‎Excellent analytical, clinical documentation, and communication skills.

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

‎Healthcare BPO or healthcare payer experience is preferred.

‎Background in Utilization Review (UR) and Utilization Management (UM), particularly Prior Authorization or Concurrent Review.

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

‎IDEAL CANDIDATE PROFILE

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‎We are specifically looking for USRN candidates with hands-on experience in Utilization Management or Utilization Review, particularly in Prior Authorization and Concurrent Review.

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‎Candidates with healthcare BPO, healthcare payer, and familiarity with InterQual or MCG will have an advantage.