Job Title : USRN Utilization Management Nurse – Prior Authorization / Concurrent Review

Location: Vertis North, Quezon City, Philippines
Work Setup: Onsite
Shift: US Day Shift

Job Description :

We are hiring Clinical Utilization Management Nurse Specialists (USRN) to support a US managed care healthcare program. The role involves reviewing prior authorization and concurrent review requests, assessing medical necessity, determining the appropriate level of care, and ensuring timely, clinically appropriate, and cost-effective healthcare services.

The ideal candidate holds an active, unrestricted US Registered Nurse (USRN) license, has passed the NCLEX, and possesses relevant clinical nursing and Utilization Management (UM), Utilization Review (UR), Prior Authorization, or Concurrent Review experience. Knowledge of Medicare, Medicaid, US managed care guidelines, and clinical decision-support tools such as InterQual or MCG is highly desirable.

Key Responsibilities

1. Clinical Utilization Review: Review prior authorization and concurrent review requests to assess medical necessity and determine the appropriate level of care using established clinical guidelines.

2. Case Coordination and Resolution: Coordinate with healthcare providers and internal teams to obtain relevant clinical information and support timely case resolution.

3. Clinical Escalation: Identify cases requiring additional clinical judgment and escalate them to Medical Directors or the appropriate clinical review team.

4. Discharge and Transfer Support: Assist with discharge planning and transfer authorization workflows for concurrent review cases.

5. Clinical Documentation and Process Guidance: Document clinical findings and decisions accurately, maintain compliance with established standards, and guide providers and internal teams on utilization management procedures.

Required Skills

1. USRN Licensure and Clinical Nursing: Bachelor of Science in Nursing (BSN) from an accredited nursing school, an active and unrestricted USRN license, and successful completion of the NCLEX.

2. Utilization Management and Utilization Review: Relevant experience in UM/UR, including Prior Authorization or Concurrent Review, meeting one of the specified clinical and UM experience pathways.

3. Medical Necessity and Level-of-Care Assessment: Ability to review clinical records and apply established guidelines to determine medical necessity and appropriate care levels.

4. US Managed Care Knowledge: Understanding of Medicare, Medicaid, US managed care fundamentals, healthcare payer workflows, and clinical documentation requirements.

5. Clinical Decision-Support Tools: Familiarity with InterQual, MCG, or similar clinical review criteria, alongside strong analytical, communication, and documentation skills.

Qualifications

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

• Active, unrestricted USRN license with NCLEX passed.

• Meet either 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.

• 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.

• Excellent clinical analysis, documentation, communication, and case management skills.

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

Important Hiring Restrictions

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

Candidates with previous employment at PSG Global, Majorel, or Aegis are also ineligible under the client's hiring restrictions, as these companies are included in the Teleperformance-related exclusion.

Candidates must confirm their employment history during screening.