Utilization Review Specialist

2 days ago

Pasig, National Capital Region, Philippines Connext Global Solutions Inc Full time ₱4,500,000 - ₱9,000,000 per year

Req ID: 1680

Connext is a dedicated team of business process outsourcing experts and innovators, with experience in supporting world-class companies in Title and Escrow, Healthcare, Produce Distribution, Retail and Fashion, Design Consulting, and Finance.

We are currently looking for a Utilization Review Specialist who will be working with Connext's Client in the United States of America.

What's in it for you?

  • Competitive compensation
  • Perfect Attendance Bonus
  • Life insurance
  • HMO Insurance
  • Great company culture
  • 25% Night Differential
  • Annual Increase
  • 25,000 Php Sign-On Bonus
  • Work from Home

What is the job?

The Utilization Review Specialist is responsible for performing audits of medical records on behalf of hospital clients to support denial reviews, defense audits, disallowed charge evaluations, and utilization reviews.

Responsibilities:

  • Conduct comprehensive medical record audits to validate or defend charges and resolve patient or payer inquiries.
  • Analyze records using InterQual, MCG, and payer guidelines to assess medical necessity and care appropriateness.
  • Prepare and support clinical and contractual appeals, including RAC, CERT, ZPIC, SMRC, and avoidable LOS cases.
  • Gather and verify supporting documentation and compose detailed, compliant appeal letters.
  • Manage multiple cases while documenting findings accurately in EMRs and client systems, ensuring HIPAA and regulatory compliance.
  • Maintain up-to-date knowledge of Medicare, Medicaid, and payer rules, participating in ongoing training and best-practice updates.

Qualifications:

  • At least three (3) years of clinical experience or equivalent in auditing, Medicare appeals, utilization review, or denials management.
  • Uses Microsoft Office, EMRs, and multiple systems effectively.
  • Reviews medical records and supports claims processing or clinical case management.
  • Applies knowledge of Medicare/Medicaid rules and compliance requirements.
  • Brings bedside nursing experience to interpret complex clinical cases.
  • Demonstrates strong attention to detail and accuracy.

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