JOB TITLE: Operations Manager for Utilization Management - USRN

LOCATION: Onsite | Bridgetowne, Quezon City

SCHEDULE: Night Shift 

SALARY RANGE: ₱150,000 – ₱180,000

START DATE: December 31, 2025 / ASAP

ROLE OVERVIEW

We are seeking an experienced Operations Manager to lead our Utilization Management operations. This critical role requires a licensed US Registered Nurse with proven leadership experience to oversee UM operations, ensure regulatory compliance, and drive team performance. You will work closely with cross-functional stakeholders to maintain high-quality healthcare management standards while managing clinical denials and utilization review processes.

KEY RESPONSIBILITIES

• Oversee daily Utilization Management operations ensuring smooth workflow


• Ensure compliance with SLAs and regulatory standards


• Monitor and maintain operational efficiency across all UM processes


• Develop and implement process improvement initiatives


• Identify opportunities for operational excellence


• Drive continuous improvement in service delivery


• Manage team performance and conduct regular evaluations


• Optimize resource allocation and staffing levels


• Coach and develop team leads and supervisors


• Foster a high-performance culture focused on quality outcomes


• Collaborate with internal teams and client stakeholders to enhance service delivery


• Maintain accurate staffing and capacity planning


• Build strong relationships to drive operational success


• Ensure strict adherence to HIPAA and other regulatory requirements


• Maintain compliance with medical guidelines (MCG, InterQual, NCQA, ODG)


• Uphold quality standards in all utilization management decisions

REQUIRED QUALIFICATIONS AND SKILLS

• Bachelor's Degree in Nursing required


• Active and valid USRN (US Registered Nurse) license - MANDATORY


• Excellent verbal and written communication skills


• Strong leadership and team management capabilities


• Strategic thinking with process improvement mindset


• Strategic operational management


• Clinical denials and appeals management expertise


• Regulatory compliance and risk management


• Team development and performance optimization


• Healthcare management process knowledge


• Stakeholder management and communication


• Data-driven decision making

Relevant Experience:

• Minimum 1-2 years in a managerial role supervising leaders, team leads, or supervisors


• Proven experience managing teams handling Utilization Management and clinical denials


• Background in handling appeals denials, utilization review, or related healthcare management functions


• Well-versed in Medical Guidelines including MCG, InterQual, NCQA, and ODG


• Strong knowledge of HIPAA and other regulatory requirements


• Understanding of industry standards and compliance protocols

Availability:

• Willing to work onsite in Bridgetowne, Quezon City


• Available to start by December 31, 2025 or immediately

APPLICATION SCREENING QUESTIONS

To expedite your application, please kindly answer the following:

1. Do you have an active USRN license?


2. How many years of experience do you have managing teams handling Utilization Management and clinical denials in healthcare or BPO/CPO settings?


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


4. Please provide your years of experience in handling utilization management and clinical appeals, and share a brief overview of your process experience.


5. Do you have strong knowledge and understanding of HIPAA and other regulatory requirements?


6. Please rate your knowledge and expertise in Medical Guidelines (MCG, InterQual, NCQA, ODG) from 1 to 10, with 10 being the highest.


7. What are your salary expectations?


8. When can you start once hired?

Join us in making a difference in healthcare utilization management. If you're a licensed USRN with strong leadership experience and expertise in utilization management, we want to hear from you!

Apply now and lead our UM operations to excellence!