Clinical Utilization Review Specialist

1 month ago


Taguig, National Capital Region, Philippines Gratitude Philippines Full time

We are seeking a highly skilled Clinical Utilization Review Specialist to join our team at Gratitude Philippines. This role is responsible for conducting thorough reviews of medical records to ensure compliance with regulatory requirements and company standards.

Key Responsibilities:
  • Conduct clinical reviews of medical records to determine medical necessity and appropriateness of care
  • Ensure compliance with regulatory requirements, including workers' compensation laws and URAC standards
  • Collaborate with healthcare providers and other stakeholders to gather information and resolve issues
  • Analyze data and identify trends to inform business decisions
Requirements:
  • Bachelor's degree in nursing (BSN)
  • Active unrestricted RN license that can be validated through the PRC website
  • 1-2 years of relevant clinical experience in any medical/surgical department, orthopedic, medical/surgical ICU, coronary care unit (CCU), rehabilitation, or emergency department
  • Written and verbal fluency in English
  • Ability to work onsite in BGC and meet US operation hours
Preferred Qualifications:
  • Proficiency in all Microsoft Office products, including Project, Word, Excel, PowerPoint, Visio, and SharePoint
  • Knowledge of workers' compensation laws and regulations, behavioral health, case management practice, URAC standards, ODG, utilization review, pharmaceuticals to treat pain, pain management process, drug rehabilitation, state workers compensation guidelines, periods of disability, and treatment needed
  • Leadership/management/motivational skills as well as analytic and strong organizational skills
  • Ability to work in a team environment and meet or exceed performance competencies
Estimated Salary:

₱480,000 - ₱600,000 per annum



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