(Urgent)Clinical Utilization Management Nurse Specialist (USRN)

# Job Description: Clinical Utilization Management Nurse Specialist (USRN)
**Program:** Healthcare – Hybrid Voice and Back-Office Operations\

**Work Location:** Vertis North, Quezon City, Philippines\

**Work Setup:** Onsite\

**Shift Schedule:** US Day Shift\

**Salary:** Open, based on experience, qualifications, and current/previous salary\

**Target Start Date:** On or before December 15, 2026\

**Number of Vacancies:** 6

## Job Overview

We are seeking qualified and experienced **Clinical Utilization Management Nurse Specialists (USRN)** to join our healthcare operations team. The successful candidates will utilize their clinical expertise to review prior authorization and concurrent review requests, assess medical necessity, and ensure appropriate, timely, and cost-effective patient care in a US managed care environment.

This role requires strong clinical judgment, knowledge of US healthcare guidelines, and experience in Utilization Review (UR), Utilization Management (UM), Prior Authorization, or Concurrent Review.

## Key Responsibilities

- Review prior authorization and concurrent review requests to determine medical necessity and appropriate levels of care.

- Evaluate clinical documentation against established medical necessity criteria and utilization management guidelines.

- Coordinate with healthcare providers, medical facilities, and internal teams to ensure timely case resolution.

- Escalate cases requiring additional clinical assessment or higher-level review to Medical Directors.

- Support discharge planning, transfer authorization, and continued-stay review processes.

- Maintain accurate and complete clinical documentation in accordance with established procedures and quality standards.

- Communicate utilization management requirements, review outcomes, and case updates to healthcare providers and internal stakeholders.

- Ensure compliance with applicable US managed care policies, Medicare and Medicaid guidelines, and organizational protocols.

- Use clinical decision-support tools, such as InterQual, MCG, or equivalent platforms, to support review decisions.

- Meet productivity, accuracy, turnaround-time, and quality targets.

## Qualifications and Requirements

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

- Active and unrestricted US Registered Nurse (USRN) license with NCLEX 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 US managed care fundamentals, including Medicare and Medicaid.

- Experience in Utilization Review (UR), Utilization Management (UM), Prior Authorization, or Concurrent Review.

- Healthcare BPO, healthcare payer, or managed care experience is preferred.

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

- Excellent clinical assessment, analytical, documentation, and communication skills.

- Strong attention to detail and the ability to make evidence-based clinical decisions.

- Willingness to work 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

Former Teleperformance employees are ineligible for rehire, whether directly or through a third party. The client also excludes candidates who have previously worked at PSG Global, Majorel, or Aegis.

## Pre-Screening Questions

Recruiters should validate the following information during the initial screening:

1. **Educational Attainment:** Have you completed a Bachelor of Science in Nursing (BSN)?

2. **USRN License:** Do you hold an active, unrestricted USRN license, and have you passed the NCLEX?

3. **Clinical Experience:** How many years of clinical experience do you have in a hospital, clinic, or academic setting?

4. **Utilization Management Experience:** How many years of experience do you have in UM, Prior Authorization, or Concurrent Review?

5. **UR/UM Background:** Do you have experience in Utilization Review or Utilization Management, particularly Prior Authorization or Concurrent Review? Please describe your responsibilities.

6. **Healthcare Industry Experience:** Have you worked in a healthcare BPO, healthcare payer, or managed care environment?

7. **US Managed Care Knowledge:** How familiar are you with Medicare, Medicaid, and US managed care guidelines?

8. **Clinical Review Tools:** Have you used InterQual, MCG, or similar clinical decision-support tools?

9. **Work Setup and Schedule:** Are you willing to work onsite at Vertis North, Quezon City, on a US day shift?

10. **Employment Eligibility:** Have you previously worked for Teleperformance, PSG Global, Majorel, or Aegis?

11. **Last Drawn Salary:** What is your current or most recent salary?

12. **Expected Salary:** What is your expected salary for this position?

## Compensation and Hiring Details

- Salary will be discussed based on the candidate's qualifications, relevant experience, current or previous compensation, and client budget.

- Candidates should have reasonable salary expectations aligned with the approved budget.

- Target joining date: on or before December 15, 2026.

- Total openings: 6.

**Ideal Candidate:** A licensed USRN with relevant clinical and utilization management experience, strong knowledge of US managed care guidelines, and the ability to make accurate, timely, and evidence-based medical necessity decisions.

Clarify the program’s hybrid wordingSeparate required and preferred qualifications