We are seeking an experienced healthcare leader to manage our clinical review operations. The ideal candidate will bring deep expertise in utilization management, claims review, and team leadership within a regulated healthcare environment.

Responsibilities:

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  Lead and supervise a team responsible for clinical review operations, ensuring compliance with medical policy, eligibility, benefits, and contractual guidelines.

  
  


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  Oversee a range of review activities, including pre-service, concurrent, retrospective, out-of-network, and treatment setting appropriateness reviews.

  
  


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  Manage the processing of service requests received via inbound calls and facsimile.

  
  


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  Ensure team members conduct necessary outbound calls to healthcare providers to gather supplemental clinical information.

  
  


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  Supervise the post-service claims review process, analyzing claims against member benefit contracts and organizational health plan guidelines.

  
  


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  Direct the completion of post-service pended claims reviews for both Medical Necessity and Contractual compliance.

  
  

Qualifications & Skills:

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  Minimum of 12 years of relevant experience in healthcare utilization management, clinical review, or a closely related field.

  
  


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  At least 10 years of demonstrated supervisory or team leadership experience.

  
  


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  Must possess a current and unrestricted US Registered Nurse license (no specific state licensure required).

  
  


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  Experience in a Business Process Outsourcing (BPO) environment is acceptable; health account experience is advantageous but not mandatory.

  
  


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  Open to candidates with diverse professional backgrounds from both BPO and non-BPO settings.

  
  


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  Applicants must be currently located in the Philippines and possess the legal right to live and work in the country without sponsorship.

  
  


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  Candidates must not have applied for any other role with our organization within a recent, specified period.

  
  


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  We seek candidates with a stable employment history, demonstrating commitment in previous roles.

  
  

If your skills and experience align with this profile, we encourage you to apply.