Work Setup: On-site in Taguig (Uptown Bonifacio Tower 3) Work Shift: Night shift Rest Days: Weekends off Location: Taguig, Philippines

We are seeking an experienced Health Clinical Services Senior Manager with a valid US Registered Nurse (USRN) license to lead clinical review teams in a dynamic healthcare operations environment. This senior leadership role involves overseeing staff responsible for medical necessity reviews, utilization management, and claims analysis while ensuring compliance with medical policies, member benefits, and regulatory standards.

Key Responsibilities:

• Oversee teams performing pre-service, concurrent, retrospective, out-of-network, and appropriateness-of-treatment reviews


• Ensure compliance with applicable criteria, medical policies, member eligibility, benefits, and contracts


• Manage inbound service requests (calls/fax) and outbound provider outreach for additional information


• Supervise post-service claims review and analysis using benefit contracts and health plan guidelines


• Lead pended claims resolution for medical necessity or contractual reviews


• Drive team performance, quality, and operational efficiency

Skills and Qualifications:

• Active and unrestricted US Registered Nurse (USRN) license (no state-specific licensure required)


• Minimum 12 years of relevant clinical or healthcare operations experience


• At least 10 years of supervisory/managerial experience


• BPO experience required (healthcare account experience is advantageous but not mandatory)


• Open to candidates with BPO or non-BPO backgrounds


• Stable employment history (no frequent job changes with less than 1 year per role)


• Currently based in the Philippines with full legal right to work


• Strong leadership, analytical, and decision-making skills in clinical review processes

7 Key Screening Questions:

1. Do you hold an active and unrestricted US Registered Nurse (USRN) license?


2. How many years of relevant clinical or healthcare operations experience do you have?


3. How many years of supervisory or managerial experience do you have?


4. How many years of experience do you have in a BPO environment?


5. How many years of continuous employment have you had in your most recent role?


6. Do you currently have the legal right to live and work in the Philippines?


7. Are you amenable to working on-site in Taguig Uptown Bonifacio Tower 3 with a night shift schedule and weekends off?