JOB DESCRIPTION: 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, and qualifications. Salary expectations should remain reasonable and aligned with the client’s budget.

Target Start Date: On or Before December 15

Headcount: 6

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).

- Active, unrestricted USRN license with NCLEX passed.

- 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.

- Excellent analytical, clinical documentation, and communication skills.

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

- 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.