Clinical Utilization Management Nurse Specialist (USRN)

We're Hiring: Clinical Utilization Management Nurse Specialist (USRN)

Location: Vertis North, Quezon City
Work Setup: 100% Onsite
Shift: US Day Shift
Salary: Negotiable, based on experience, qualifications, and current/previous compensation
Target Start Date: On or before December 15, 2026
Open Positions: 6

Job Overview

We are looking for qualified USRN-licensed nurses to join our healthcare operations team as Clinical Utilization Management Nurse Specialists. In this role, you will use your clinical expertise to evaluate prior authorization and concurrent review requests, assess medical necessity, and help ensure members receive appropriate, timely, and cost-effective 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.

• Evaluate cases using established clinical guidelines and medical necessity criteria.

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

• Escalate cases requiring additional clinical assessment to Medical Directors.

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

• Maintain accurate and comprehensive clinical documentation in accordance with established standards.

• Educate and 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 and unrestricted USRN license with NCLEX successfully passed.

• Must 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.

• Experience in a healthcare BPO or healthcare payer environment 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.

• Excellent analytical, clinical documentation, and communication skills.

• Willing to work 100% onsite at Vertis North, Quezon City, on a US day shift.

Important Hiring Restrictions

Candidates with previous employment at the following companies are not eligible for this opportunity:

• Teleperformance (TP)

• PSG Global

• Majorel

• Aegis

This restriction applies to direct and third-party hiring arrangements, in accordance with the client's hiring policy.

Compensation

Salary is open for discussion and will depend on the candidate's qualifications, relevant experience, current or previous salary, and alignment with the client's budget. Candidates are encouraged to provide reasonable salary expectations.

How to Apply

Interested and qualified candidates are invited to complete the prescreening questionnaire below.

Prescreening Questionnaire: https://myglit.com/lateral/cref/24c25d6025

Please ensure that all information provided is accurate and complete. Qualified candidates will be contacted regarding the next steps in the recruitment process.