Utilization Review Coordinator

6 days ago

Manila, Philippines Health Business Solutions LLC Full time

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

Required:

  • 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.
  • Moderate computer proficiency – Microsoft Office Suite.
  • Team-oriented approach.
  • Independent functioning and autonomy.

Strongly preferred qualifications:

  • Previous experience in utilization review/management.
  • Experience with InterQual and/or Milliman Care Guidelines.
#J-18808-Ljbffr

  • Utilization Review Coordinator

    1 week ago

    Manila, Philippines Health Business Solutions Full time

    Overview Utilization Review Coordinator position at Health Business Solutions. This role oversees patient insurance certification, compliance with governmental regulations related to hospital stays, and the prevention of denials. The Utilization/Risk Management department conducts perspective, concurrent, and retrospective reviews for authorization of Levels...

  • Utilization Review Nurse

    6 days ago

    Manila, Philippines Health Business Solutions LLC Full time

    Utilization Review Nurse Location: Philippines About Us: HBiz is a leading Revenue Cycle Management (RCM) company dedicated to helping healthcare providers optimize their financial performance. We specialize in delivering innovative solutions that streamline revenue cycle operations and enhance overall revenue generation for healthcare organizations. Our...

  • PHRN - Utilization Review

    2 days ago

    Manila, National Capital Region, Philippines PMConsulting Full time ₱600,000 per year

    You'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,...

  • Utilization Review Nurse

    2 weeks ago

    , Metro Manila, Philippines Buscojobs Full time

    Makati, National Capital Region - Dempsey Resource Management Inc. Posted 7 days ago Job Description Qualifications: A graduate of Nursing (BSN) Licensed Nurse Must have training, certification, and at least one (1) year experience relevant to the job. Good communication skills. Computer literate with proficiency in MS Office, using MS Word, and MS Excel. ...

  • USRN BPO

    2 weeks ago

    , Metro Manila, Philippines NTT DATA North America Full time

    Overview Join to apply for the USRN BPO - Utilization Review Supervisor role at NTT DATA North America Responsibilities Manages a staff of professional-level team members or manages a team through lower-level supervisors manging healthcare Payer claims adjudication process Works within general policies and management guidance, independently determining...

  • Oracle Utilities Developer

    4 days ago

    Manila, National Capital Region, Philippines NYGC Services, Inc. Full time $104,000 - $130,878 per year

    What 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...

  • Utility Billing Associate

    4 days ago

    Manila, National Capital Region, Philippines Extenteam Inc. Full time ₱400,000 - ₱600,000 per year

    We are looking for a Utility Billing Associatefor a Property management client of ours.  As a Utility Bills Associate, you will be responsible for ensuring that all utility invoices are accurately processed and recorded for each property. You will work closely with the client to maintain organized records, enter invoices into AppFolio with the correct...

  • Sr Dry Utilities Engineer

    1 week ago

    Manila, Philippines CBS Comprehensive Business Services Full time

    Overview CBS is seeking a highly skilled Sr Dry Utilities Engineer to join our expert team. In this senior role, you will be responsible for overseeing the design, planning, and implementation of dry utility systems, which include electricity, gas, telecommunications, and other utility infrastructures. You will play a crucial role in ensuring that these...

  • Utility Engineer 1

    4 weeks ago

    Manila, National Capital Region, Philippines Zeitview (formerly DroneBase) Full time

    About Us:Zeitview is the leading intelligent aerial imaging company for high-value infrastructure, providing businesses with actionable, real-time insights to recover revenue, reduce risk and improve build quality. We serve customers in the solar, wind, insurance, construction, real estate, and critical infrastructure industries. Trusted by the largest...

  • Utility Team Lead

    4 weeks ago

    Manila, National Capital Region, Philippines Zeitview (formerly DroneBase) Full time

    About Us:Zeitview is the leading intelligent aerial imaging company for high-value infrastructure, providing businesses with actionable, real-time insights to recover revenue, reduce risk and improve build quality. We serve customers in the solar, wind, insurance, construction, real estate, and critical infrastructure industries. Trusted by the largest...