Clinical Utilization Management Nurse Specialist (USRN)

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

• Apply established clinical guidelines and criteria to support accurate and timely utilization management decisions.

• Coordinate with healthcare providers and internal teams to ensure timely case resolution.

• Escalate cases requiring additional clinical evaluation to Medical Directors.

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

• Maintain accurate clinical documentation in accordance with established standards and procedures.

• Guide healthcare providers and internal stakeholders on utilization management processes.

• Ensure compliance with applicable Medicare, Medicaid, and US managed care guidelines.

• Meet established quality, productivity, and turnaround time requirements.

Qualifications

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

• Active, unrestricted US Registered Nurse (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.

• 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 tools.

• Strong analytical, clinical documentation, communication, and decision-making skills.

• Willingness to work onsite at Vertis North, Quezon City, on a US day shift.

Important Hiring Restrictions

• Former Teleperformance (TP) employees are not eligible for rehire, either directly or through a third party.

• Candidates previously employed by PSG Global, Majorel, or Aegis are also ineligible under the client's hiring restrictions.

Prescreening Questions

1. Educational Attainment: What is your highest educational attainment? Did you graduate with a Bachelor of Science in Nursing (BSN)?

2. USRN License: Do you have 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 Utilization Management, Prior Authorization, or Concurrent Review?

5. UR/UM Background: Do you have experience in Utilization Review (UR) or Utilization Management (UM), particularly Prior Authorization or Concurrent Review? Please provide details.

6. Healthcare Industry Experience: Do you have experience working in a healthcare BPO or healthcare payer 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. Previous Employment: Have you previously worked for Teleperformance (TP), PSG Global, Majorel, or Aegis?

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

11. Last Drawn Salary: What was your most recent monthly salary?

12. Expected Salary: What is your expected monthly salary?