Medical Necessity Specialist

12 hours ago

Pasig, National Capital Region, Philippines beBeeCaregiver Full time ₱800,000 - ₱1,200,000
Utilization Review Nurse

The primary role of this position is to ensure patients receive appropriate, timely, and cost-effective care by reviewing medical records, treatment plans, and healthcare resource utilization.

  • Conduct concurrent and retrospective reviews of patient clinical information to guarantee 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.
Requirements
  • 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 is preferred.
  • Strong knowledge of clinical guidelines and medical necessity criteria is preferred.
  • 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.
Benefits
  • 15% Night Differential
  • HMO coverage after 30 days of employment
  • 24 Leave Credits per year (convertible to cash)
  • Wholistic Employee Wellness Program
  • Supportive and inclusive environment

This organization values professional growth, employee well-being, and long-term partnerships.

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