(Urgent)Clinical Utilization Management Nurse Specialist (USRN)

WE ARE HIRING

Clinical Utilization Management Nurse Specialist (USRN)

Program: Healthcare – Hybrid Voice and Back-Office Operations

Work Location: Vertis North, Quezon City

Work Setup: Onsite

Shift Schedule: US Day Shift

Salary: Open, depending on the candidate’s current or previous salary, experience, and qualifications. Salary expectations should remain reasonable and aligned with the client’s budget.

Target Start Date: On or before December 15

Job Overview

Use your clinical expertise to review prior authorization and concurrent review requests against established clinical guidelines. Ensure members receive appropriate, timely, and cost-effective care within a US managed care environment.

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 ensure timely case resolution.

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

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

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

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

Qualifications

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

• Active, unrestricted USRN license with NCLEX passed.

• 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.

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

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