Utilization Review Coordinator
1 week ago
Job Summary We are seeking a skilled Utilization Review Coordinator (URC) to oversee patient insurance certification, compliance with governmental regulations related to hospital stays, and the prevention of denials. Embedded within our utilization review management platform are clinical criteria guidelines, streamlining the review and documentation process. The Utilization/Risk Management department conducts perspective, concurrent, and retrospective reviews for authorization of Levels of Care (LOCs) and services, engaging with Program Managers, reviewing medical necessity records, and liaising with individuals and their families when necessary. Additionally, the department handles billing and payroll functions. Primary Responsibilities Evaluate patient records to assess severity of illness and intensity of service Apply medical necessity screening criteria and clinical knowledge to ensure appropriateness of admissions and length of stays Conduct initial admission, continuing stay, and 23-hour observation reviews for all patients Manage case reviews in the electronic utilization review system Collaborate with payor sources to communicate clinical information and secure hospital reimbursement Consult with physicians and nursing staff Participate in interdisciplinary care rounds for effective communication with the care team Use escalation pathways to resolve identified issues Document all activities and interactions in the electronic utilization review record Enhance customer satisfaction among patients, families, physicians, internal and external partners, payors, and vendors Submit Initial and Concurrent Authorizations to insurance companies Verify client insurance coverage for authorization submission Coordinate with insurance companies to resolve billing or authorization issues Communicate Billing and Payroll questions from Program Managers and ensure accurate documentation before billing claims Review Service Verification Forms and Time sheets to ensure precise payroll processing Participate in state and local audits Adhere to policies, procedures, regulations, and standards governing the agency Maintain strict confidentiality according to Federal and State guidelines Uphold the Professional Code of Ethics Other duties as assigned Qualifications Bachelor’s degree in nursing, physical therapy, medical technician, HIMS, or a related medical field Managed Care or Health Plan experience Detail-oriented Effective oral and written communication skills Team-oriented approach Independent functioning and autonomy Preferred Qualifications Previous experience in utilization review/management Experience with InterQual and/or Milliman Care Guideline #J-18808-Ljbffr
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Utilization Review Coordinator
4 days ago
Manila, National Capital Region, Philippines Health Business Solutions Full time ₱900,000 - ₱1,200,000 per yearUtilization Review CoordinatorJOB SUMMARYWe are seeking a skilled Utilization Review Coordinator (URC) to oversee patient insurance certification, compliance with governmental regulations related to hospital stays, and the prevention of denials. Embedded within our utilization review management platform are clinical criteria guidelines, streamlining the...
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Utilization Review Coordinator
2 weeks ago
Manila, National Capital Region, Philippines Health Business Solutions Full timeJOB SUMMARYWe are seeking a skilled Utilization Review Coordinator (URC) to oversee patient insurance certification, compliance with governmental regulations related to hospital stays, and the prevention of denials. Embedded within our utilization review management platform are clinical criteria guidelines, streamlining the review and documentation process....
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PHRN - Utilization Review
2 weeks ago
Manila, National Capital Region, Philippines PMConsulting Full time ₱600,000 per yearYou'll be responsible for reviewing medical records and clinical documentation todetermine the medical necessity, appropriateness, and efficiency of healthcare servicesprovided. You'll work closely with physicians, case managers, and insurance providers toensure optimal patient care while supporting cost containment efforts.Job Types: Full-time,...
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Medical Review Specialist
7 days ago
Manila, National Capital Region, Philippines TakeCare Insurance Company, Inc. Full time ₱300,000 - ₱600,000 per yearJob Specifications:Graduate of Bachelor's Degree – RN License is required.Minimum of 2 years experience and must have impressive track record in reviewing treatment plans and services to ensure the efficient use of patient utilization systems and quality care using appropriate medical resources.Effective team player. Excellent interpersonal relationship...
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Medical Review Specialist
3 weeks ago
Manila, Philippines TakeCare Insurance Company, Inc. Full timeJob Specifications Open to hybrid work arrangement. Graduate of Bachelor’s Degree - RN License is required. Minimum of 2 years experience and must have impressive track record in reviewing treatment plans and services to ensure the efficient use of patient utilization systems and quality care using appropriate medical resources. Effective team player...
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Southern Manila District, Philippines access healthcare Full timeUtilization Management Specialist (PHRN / Non-Voice) Join our dynamic healthcare team and make an impact by improving patient outcomes, ensuring compliance, and driving efficient healthcare delivery for our global clients. ✅ Ideal Candidate Must be a Philippine Registered Nurse (PHRN) with an active license. 1–2 years of experience in Utilization Review,...
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Utilization Review Nurse | UMR | PHRN | Pasay
3 weeks ago
Southern Manila District, Philippines Access Healthcare Services Manila, Inc. Full timeOverview We are seeking a highly skilled and detail-oriented PH Registered Nurse (PHRN) to join our team. The ideal candidate will have hands-on experience with InterQual , MCG , NCD , and LCD Guidelines. Key Responsibilities Conduct clinical reviews of inpatient and outpatient services using InterQual, MCG, NCD, and LCD criteria. Analyze patient records to...
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Southern Manila District, Philippines Access Healthcare Services Manila, Inc. Full timeWe are seeking a highly skilled and detail-oriented PH Registered Nurse (PHRN) to join our team. The ideal candidate will have hands-on experience with InterQual , MCG , NCD , and LCD Guidelines . Key Responsibilities Conduct clinical reviews of inpatient and outpatient services using InterQual, MCG, NCD, and LCD criteria. Analyze patient records to...
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Oracle Utilities Developer
2 weeks ago
Manila, National Capital Region, Philippines NYGC Services, Inc. Full time $104,000 - $130,878 per yearWhat you'll be doingDesign, develop, and implement new features and enhancements for our Oracle Utilities platformTroubleshoot and resolve issues within the Oracle Utilities application and underlying infrastructureCollaborate with cross-functional teams to understand business requirements and translate them into technical solutionsParticipate in code...
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Distribution Utility Tariff Manager
4 days ago
Manila, Philippines KSearch Asia Consulting, Inc. Full timeClient Our client is a Cebu-based PSE-listed company engaged in electric power generation for both renewable and non‑renewable energy, electric power distribution and retail electricity business. They also ventured into water and infrastructure business. Job Description The Distribution Utility Tariff Manager will be responsible for developing,...
