Utilization Review Nurse

4 weeks ago

Pasig, Philippines VISAYA Full time

Overview

Visaya Knowledge Process Outsourcing Corporation is a proudly Filipino organization recognized globally for service excellence, innovation, and a culture of malasakit. We are committed to building long-term partnerships through quality, reliability, and a people-first approach.

Role: Utilization Management / Review Nurse

We are seeking a skilled Utilization Management/Review Nurse to join our team. This role is essential in ensuring patients receive appropriate, timely, and cost-effective care by reviewing medical records, treatment plans, and healthcare resource utilization.

Key Responsibilities
  • Conduct concurrent and retrospective reviews of patient clinical information to ensure medical necessity, appropriateness, and efficiency of services.
  • Review precertification and authorization requests for inpatient and outpatient care against established clinical guidelines and payer policies.
  • Collaborate with physicians, case managers, and healthcare professionals to coordinate care and discharge planning.
  • Analyze utilization trends and identify opportunities for improving resource use and cost-effectiveness while maintaining quality care.
  • Maintain accurate documentation of all utilization review activities and patient interactions.
  • Provide daily updates and reports to the Utilization Management Manager.
  • Educate healthcare staff and providers on utilization management policies and best practices.
  • Ensure compliance with regulatory requirements and internal policies related to utilization management.
  • Serve as a patient advocate to promote appropriate care and prevent unnecessary hospitalizations or procedures.
Qualifications
  • Graduate of BS Nursing with an active USRN license.
  • At least 2-4 years of solid experience in Utilization Review and Management.
  • Prior hospital experience, preferred
  • Strong knowledge of clinical guidelines and medical necessity criteria is preferred (MCG/Interqual, etc.)
  • Excellent analytical, organizational, and communication skills.
  • Ability to work independently in a fast-paced environment.
  • Willingness to work onsite in Ortigas and on a night shift schedule.
  • Utilization Management or Case Management certification is a plus.
Perks and Benefits
  • 15% Night Differential
  • HMO coverage after 30 days of employment (with option to add up to 2 dependents)
  • 24 Leave Credits per year (convertible to cash)
  • Wholistic Employee Wellness Program
  • Be part of a multi-awarded, 100% Filipino-owned company recognized for its leadership and innovation in the outsourcing industry.
  • Work in a culture that values professional growth, employee well-being, and long-term partnerships.
  • Enjoy industry-leading benefits and a supportive, inclusive environment.

Visaya KPO is an equal opportunity employer. We celebrate diversity and are committed to creating an inclusive environment for all employees.

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