USRN - Lead/SME (Hybrid, MCG & Interqual Exp Required)

2 days ago

Taguig, National Capital Region, Philippines UST Full time $60,000 - $80,000 per year

Under general supervision, the Lead is responsible for supervising the assigned team and ensure that the team adheres to SLAs specified by the client or process for productivity, achieving expected quality and revenue goals and schedule adherence. The Lead is considered a mentor, trainer, developer of less tenured team members. Responsible for developing new and existing audit concepts.

  • Maintain KPI for assigned sites and assist team with meeting deadlines, as needed
  • Work with other leads and managers (Client) to resolve issues or escalations resulting from any errors
  • Hold team accountable for meeting deadlines, completing monthly reconciliation, completing missing information, and effectively report delays and issues in a timely manner
  • Review and analysis of periodic reports and metrics
  • Will be accountable for daily/weekly performance updates to key stakeholders in weekly meetings
  • Responsible for managing attrition and building retention strategies
  • Providing regular performance feedback, giving frequent formal and informal coaching sessions and best practice sharing for accurate processing
  • Responsible for queue management, shift staffing and roster management as applicable.
  • Provide support to quality initiatives targeted towards process improvements
  • Assist in hiring new team members
  • Perform other duties as assigned
  • Willing to go the extra mile when needed
  • Should be comfortable handling remote staff and office-based staff

Qualifications:

  • Must have active USRN mainland license
  • AHIMA or AAPC medical coding certification not required but an advantage
  • Lean Training and Certification an advantage

Work Experience:

  • Should have overall 5+ year work experience with a minimum of 2 years in the role of Supervisor in a BPO setting with knowledge on one or all fields or medical Utilization Management and Review.
  • Profound understanding and application of Milliman and Interqual guidelines
  • Should have the ability to effectively handle large teams in a fast-moving business environment
  • Must be comfortable creating process workflows and documenting processes
  • Understanding and well versed in the application and process of Utilization Management, and/ or Appeals and Grievance

Other requirements:

  • Proficient knowledge on US Healthcare Practice, Clinical Documentation Improvement, medical terminologies, EDI, and HIPAA protocols are a must
  • Excellent collaboration skills and good work ethics
  • Excellent verbal and written business communication skills required
  • Strong proficiency in Windows OS and Microsoft Office applications
  • Self-starter who can manage multiple priorities with minimum direction
  • Knowledge on different platforms used in the conduction of UM reviews

  • USRN Quality Analyst

    2 days ago

    Taguig, National Capital Region, Philippines Access Healthcare Services Manila, Inc. Full time $60,000 - $80,000 per year

    We currently looking for USRN Quality Analyst to be part of our PIONEER USRN TEAM This role focuses on the comprehensive analysis, management, and resolution of denials and appeals related to claims and services, ensuring compliance with insurance policies, healthcare regulations, and industry best practices.Key Responsibilities: Denials and Appeals...

  • USRN Trainer

    2 days ago

    Taguig, National Capital Region, Philippines Access Healthcare Services Manila, Inc. Full time $60,000 - $80,000 per year

    We currently looking for USRN Trainer to be part of our PIONEER USRN TEAM In this role, you will be responsible for developing and delivering comprehensive training programs for staff involved in the denials and appeals process. The ideal candidate will have a strong clinical background, expertise in appeals management, and a passion for teaching and...

  • PHRN Quality Auditor – Clinical Authorization

    2 days ago

    Taguig, National Capital Region, Philippines Nezda Technologies, Inc. Full time $40,000 - $60,000 per year

    WE'RE HIRING: QUALITY AUDITOR – CLINICAL AUTHORIZATION Join our dynamic healthcare team and make an impact in clinical quality assurance Qualifications • Active PHRN license (USRN license holders are not eligible) • Proven experience as a Quality Auditor in Clinical Services within a healthcare BPO – Alternatively, 4–7 years of focused...

  • Clinical Appeals Nurse

    2 days ago

    Taguig, National Capital Region, Philippines KMC Solutions Full time $60,000 - $80,000 per year

    Make your next big career move by applying as KMC Solutions' next PHRN – CLINICAL DENIALS AND APPEALS The PHRN - Clinical Denials and Appeals is responsible for reviewing and addressing medical necessity and authorization-related claim denials by conducting thorough clinical reviews, preparing appeal letters, and communicating effectively with payers. This...

  • Clinical Authorization Specialist

    7 days ago

    Taguig, National Capital Region, Philippines beBeeClinicalAuthorization Full time ₱30,000 - ₱45,000

    About Our RoleWe are seeking a skilled professional to join our team in the field of Utilization Review and Clinical Authorization.Job OverviewThis role is responsible for conducting audits in accordance with Quality Improvement Plans (QIP), providing actionable feedback, and tracking corrections. Additionally, this position involves verifying patient...

  • Clinical Authorization Process Specialist

    7 days ago

    Taguig, National Capital Region, Philippines beBeeAuthorization Full time ₱1,200,000 - ₱2,000,000

    Healthcare Authorization SpecialistQuality Auditor hiring Clinical Authorization Process.Must hold an active PHRN license (not a USRN license holder)Relevant experience as a Quality Auditor in Clinical Services within a healthcare environment; alternatively, 4 to 7 years of specialized experience in Clinical Authorization or Utilization Review is...

  • UM Nurse SME

    2 days ago

    Taguig, National Capital Region, Philippines UST Full time $60,000 - $80,000 per year

    Responsibilities:Perform prospective, concurrent, and retrospective reviews of inpatient, outpatient, ambulatory and ancillary services to ensure medical necessity, appropriate length of stay, the intensity of service, and level of care, including appeal requests initiated by providers, facilities, and members.Review, research, and prepare documentation...

  • PHRN - Utilization Review / Clinical Authorization

    7 days ago

    Taguig, National Capital Region, Philippines HR TechX Corp. Full time

    OverviewWe are hiring for the PHRN - Utilization Review / Clinical Authorization role at HR TechX Corp. Location: Onsite, Mckinley, Taguig. Schedule: Night Shift | Monday to Friday. Hiring Target Date: Preferably by July 21, 2025. Salary Range: Up to 50k.QualificationsActive PHRN license (Not a USRN)Prior experience as a Quality Auditor in a healthcare BPO...

  • Work From Home_PHRN

    2 days ago

    Taguig, National Capital Region, Philippines HR TechX Corp. Full time ₱500,000 - ₱1,000,000 per year

    Philippine Registered Nurse should have:Minimum of 1 year of direct bedside care experience in an acute care hospital setting (excluding clinics), with a strong preference for backgrounds in Emergency Room (ER), Intensive Care Unit (ICU), Medical-Surgical, Neonatal Intensive Care Unit (NICU), or Operating Room (OR) environmentsAt least 1 year of hands-on...

  • BPM Lead

    2 days ago

    Taguig, National Capital Region, Philippines UST Full time $60,000 - $80,000 per year

    Role DescriptionUnder general supervision, the Lead is responsible for supervising the assigned team and ensure that the team adheres to SLAs specified by the client or process for productivity, achieving expected quality and revenue goals and schedule adherence. The Lead is considered a mentor, trainer, developer of less tenured team members. Responsible...