Utilization Review Nurse

3 days ago

Quezon City, National Capital Region, Philippines Private Advertiser Full time ₱1,000,000 - ₱2,500,000 per year

**What we offer:

Salary Package: PHP 50,000 +**

Sign-On Bonus: PHP 50,000

Work Setup: Onsite at Bridgetowne, Quezon City

Schedule: Shifting Schedule

Essential Duties and Responsibilities

  • Accurately interpret member benefits and managed care products, and guide members to appropriate providers, programs, or community resources.
  • Collaborate with medical directors to assess the appropriateness of care and ensure the accuracy of medical claims.
  • Conduct pre-certification, continued stay reviews, care coordination, and discharge planning to ensure compliance with applicable criteria, medical policies, member eligibility, benefits, and contracts.
  • Support accreditation efforts by understanding, interpreting, and correctly applying accrediting and regulatory requirements and standards.
  • Ensure member access to necessary, high-quality healthcare in a cost-effective setting as outlined by contract terms.
  • Consult with clinical reviewers and medical directors to ensure that care remains medically appropriate, high-quality, and cost-effective throughout the medical management process.
  • Work closely with providers to identify member needs early and facilitate proactive discharge planning.
  • Coordinate smooth member care transitions across the healthcare continuum.
  • Refer care or treatment plans to clinical reviewers as required (does not issue non-certifications).

Minimum Hiring Qualifications

  • Education: Bachelor's degree in Nursing
  • Experience: Minimum of 2 years of BPO clinical experience (specifically in utilization management, appeals management, or denials).
  • License: Current, active, and unrestricted license to practice as a Registered Nurse (PHRN).
  • Skills: Strong oral, written, and interpersonal communication skills; problem-solving, facilitation, and analytical skills

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