Utilization Review Nurse

5 days ago

Pasay, National Capital Region, Philippines Access Healthcare Services Manila, Inc. Full time ₱1,200,000 - ₱2,400,000 per year

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 determine the medical necessity and appropriateness of services.
  • Collaborate with medical directors and multidisciplinary teams to review complex cases.
  • Ensure compliance with regulatory and payer-specific guidelines.
  • Document and maintain accurate and comprehensive review records.
  • Participate in quality improvement and audit initiatives.
Qualifications
  • Active PHRN license
  • at least 1 year of clinical nursing experience in utilization review or case management experience preferred.
  • Must have minimum acute bedside experience
  • Proficient in using InterQual and MCG guidelines.
  • Strong working knowledge of NCD and LCD criteria and application.
  • Experience in developing or implementing clinical decision trees or algorithms.

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