Job Summary

We are seeking qualified and experienced US Registered Nurses (USRNs) to join our Healthcare program as Clinical Utilization Management Nurse Specialists.

In this role, you will leverage your clinical knowledge and nursing expertise to review prior authorization and concurrent review requests against established clinical guidelines. You will help ensure that members receive appropriate, timely, and cost-effective healthcare services within a US managed care environment.

Program: Healthcare – Hybrid Voice and Back-Office Operations
Work Location: Vertis North, Quezon City
Work Arrangement: 100% On-site
Work Schedule: US Day Shift
Salary: Open, depending on the candidate's current or previous salary, relevant experience, and qualifications. Salary expectations should remain reasonable and aligned with the client's budget.
Target Start Date: On or before December 15

Key Responsibilities

• Review prior authorization and/or concurrent review requests to determine medical necessity and the appropriate level of care based on established clinical guidelines.

• Coordinate with healthcare providers and internal teams to facilitate timely case reviews and resolutions.

• Escalate cases requiring higher-level clinical assessment or decision-making to Medical Directors.

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

• Accurately document clinical findings, review outcomes, and case decisions in accordance with established standards and procedures.

• Provide guidance to healthcare providers and internal teams regarding utilization management processes and requirements.

• Ensure timely and accurate handling of clinical review requests while maintaining quality and operational standards.

Qualifications and Experience

Educational and Licensing Requirements

• Graduate of an accredited nursing school with a Bachelor of Science in Nursing (BSN).

• Must hold an active and unrestricted US Registered Nurse (USRN) license.

• Must have successfully passed the NCLEX examination.

Professional Experience

Candidates must meet either of the following experience requirements:

• At least one (1) year of clinical experience in a hospital, clinic, or academic setting, combined with at least one (1) year of Utilization Management experience; OR

• At least two (2) years of relevant experience in Utilization Management, Prior Authorization, or Concurrent Review.

Technical Knowledge and Competencies

• Strong understanding of Medicare, Medicaid, and US managed care fundamentals.

• Experience in a healthcare BPO or healthcare payer environment.

• 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.

• Excellent analytical skills and the ability to assess clinical information against established guidelines.

• Strong clinical documentation and written and verbal communication skills.

• Ability to coordinate effectively with healthcare providers, Medical Directors, and internal teams.