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
TARGET START DATE: On or before December 15, 2026

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) – required


Active, unrestricted USRN license with NCLEX passed – required


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 – required


Strong understanding of Medicare, Medicaid, and US managed care fundamentals – required


Excellent analytical, clinical documentation, and communication skills


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


Preferred: Healthcare BPO or healthcare payer experience


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


Preferred: Familiarity with InterQual, MCG, or similar clinical decision-support criteria tools


Why Join?

Competitive salary (open, aligned with experience)


Prime Vertis North, Quezon City location


US Day Shift schedule


Career growth in utilization management and healthcare operations


Dynamic and supportive team environment