Clinical Utilization Management Nurse Specialist (USRN)

Job Overview

We are looking for a licensed US Registered Nurse (USRN) to support clinical utilization management within a US managed care environment. You will review prior authorization and concurrent review requests against established clinical guidelines to help ensure members receive appropriate, timely, and cost-effective care.

Key Responsibilities

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

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

• Escalate cases requiring higher-level clinical review to Medical Directors.

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

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

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

Qualifications

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

• Active, unrestricted US Registered Nurse (USRN) license; NCLEX must be passed.

• Either:

  • 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.

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

• Healthcare BPO or healthcare payer experience.

• Excellent analytical, clinical documentation, and communication skills.

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

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

Important Hiring Restrictions

Candidates previously employed by Teleperformance (TP), PSG Global Solutions, Majorel, or Aegis are ineligible under the client's hiring restrictions, including employment directly or through a third party.

Recruitment Process

Candidates will undergo profile validation, profile review, and the applicable interview stages as advised by the recruitment team.

Interested candidates should be prepared to discuss their clinical background, utilization management experience, USRN license status, current or last-drawn salary, and expected salary.