Job title : Clinical Utilization Management Nurse Specialist (USRN)

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Work Location: Vertis North, Quezon City, Philippines
Work Setup: Onsite
Work Shift: US Day Shift
Experience: 1-6yrs

Job Description : 

We are seeking a qualified Clinical Utilization Management Nurse Specialist with an active, unrestricted USRN license and strong clinical judgment. You will review prior authorization and concurrent review requests against established clinical guidelines to assess medical necessity, determine appropriate levels of care, and support timely, cost-effective healthcare delivery within a US managed care environment.

Key Responsibilities :

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

2. Coordinate with healthcare providers and internal teams to support timely case resolution and clarify clinical information.

3. Escalate complex cases or cases requiring higher-level clinical judgment to Medical Directors.

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

5. Document clinical findings and case decisions accurately, and guide providers and internal teams on utilization management processes.

Required Skills :

1. Active, unrestricted US Registered Nurse (USRN) license with NCLEX passed.

2. Knowledge of Utilization Management (UM), Utilization Review (UR), Prior Authorization, or Concurrent Review.

3. Understanding of US managed care fundamentals, including Medicare and Medicaid.

4. Strong clinical assessment, analytical reasoning, and clinical documentation skills.

5. Effective written and verbal communication and coordination skills.

Qualifications :

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

• Must hold an active, unrestricted USRN license and have passed the NCLEX.

• Meet one of the following experience requirements:​

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