Utilization Review Nurse

6 days ago

Pasay, National Capital Region, Philippines Access Healthcare Services Manila, Inc. Full time ₱500,000 - ₱1,000,000 per year

We are seeking a detail oriented and experienced Registered Nurse (RN) to join our PIONEER TEAM as a Virtual Utilization Review Nurse.

You'll be responsible for reviewing medical records and clinical documentation to determine the medical necessity, appropriateness, and efficiency of healthcare services provided. You'll work closely with physicians, case managers, and insurance providers to ensure optimal patient care while supporting cost containment efforts.

Key Responsibilities:
  • Conduct utilization reviews using evidence-based clinical criteria (e.g., MCG, InterQual).
  • Evaluate the appropriateness of healthcare services and ensure alignment with payer policies and regulatory guidelines.
  • Collaborate with healthcare providers and internal teams to gather clinical information.
  • Prepare and document review findings, including approvals, denials, and referrals for peer review or further evaluation.
  • Maintain up-to-date knowledge of industry guidelines, insurance regulations, and healthcare standards.
  • Meet established productivity, quality, and turnaround time benchmarks.
  • Support appeals processes as needed with clinical justifications.
Qualifications:
  • Active PRC License
  • At least 1 year experience in acute hospital settings
  • At least 1 year of experience in utilization review, case management, or medical management in BPO set up
  • Strong knowledge of medical terminology and utilization management guidelines (InterQual, MCG).
  • Strong knowledgeable in EPIC/CERNER
  • Excellent communication and documentation skills.
  • Proficient in electronic medical records (EMR) and UR platforms.
Work Set up:
  • Work onsite at Pasay
  • Permanent night shift

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