Utilization Review Nurse

1 week 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

  • Registered Nurse

    2 weeks ago

    Quezon City, National Capital Region, Philippines ECLARO Full time ₱40,000 - ₱80,000 per year

    Job SummaryPhilippine Registered Nurses (PHRNs) are responsible for collaborating with healthcare providers and members to promote quality outcomes, optimize member benefits, and ensure the effective use of resources. You will play a key role in ensuring that medically appropriate, high-quality, and cost-effective care is provided by assessing the medical...

  • Operations Manager – Utilization Management

    2 weeks ago

    Quezon City, National Capital Region, Philippines Comrise Full time ₱600,000 - ₱800,000 per year

    Job Summary:The Operations Manager for Utilization Management is responsible for managing and overseeing UM operations, ensuring compliance with industry standards and regulatory requirements. The role involves close collaboration with various stakeholders to drive performance and maintain high-quality standards.Key ResponsibilitiesOversee daily operations...

  • School Nurse

    2 weeks ago

    Quezon City, National Capital Region, Philippines ECLARO Full time ₱300,000 - ₱600,000 per year

    Role Title:School NurseECLARO: A quick SummaryECLARO is an award-winning professional services firm headquartered in New York City and operating in the U.S., Canada, UK, Ireland, Australia and the Philippines. We are dedicated to a singular purpose: providing the Right People to meet every client's needs and solve business challenges through strategic...

  • ph registered nurse

    2 weeks ago

    Quezon City, National Capital Region, Philippines Lean Solutions Group Inc. Full time ₱400,000 - ₱800,000 per year

    Job Summary:PH Registered Nurse(s) are Responsible for Collaborating with Healthcare Provider(s) and Member(s) to Promote Quality Member Outcome(s), to Optimize Member Benefit(s), and to Promote the Effective Use of Resource(s). You will help Ensure that Medically Appropriate, High Quality, and Cost-Effective Care is Provided through Assessing the Medical...

  • PH Registered Nurse

    2 weeks ago

    Quezon City, National Capital Region, Philippines Private Advertiser Full time ₱60,000 - ₱120,000 per year

    PHRNs are responsible for collaborating with healthcare providers and members to promote quality outcomes, optimize member benefits, and ensure the effective use of resources. You will play a key role in ensuring that medically appropriate, high-quality, and cost-effective care is provided by assessing the medical necessity of inpatient admissions,...

  • Intensive Care Unit Nurse

    2 weeks ago

    Quezon City, National Capital Region, Philippines DR. JESUS C. DELGADO MEMORIAL HOSPITAL Full time ₱1,000,000 - ₱2,000,000 per year

    INTENSIVE CARE UNIT NURSE (ICU)JOB SUMMARY:A professional nurse who is delegated the authority and responsibility of patient care in the Intensive Care Unit. Responsible for carrying out doctor's orders accurately; and management of the physical environment of the unit. Performs / coordinates with all the departments of the hospital as needed.DUTIES AND...

  • Company Nurse

    2 weeks ago

    Makati City, National Capital Region, Philippines Business Process Outsourcing International, Inc. Full time

    Job SummaryEnsure employees receive quality patient care in accordance with professional and company standards.Support the company's compliance with Occupational Health and Safety Administration (OSHA) regulations.Duties and ResponsibilitiesAssess nursing care needs of employees and provide first aid treatment, medications, and health assessments.Observe...

  • Company Nurse

    1 week ago

    Makati City, National Capital Region, Philippines Lean Solutions Group Full time ₱1,200,000 - ₱2,400,000 per year

    We are seeking a dedicated and detail-oriented Company Nurse to join our team. This position is ideal for candidates with experience in workplace health management, employee medical benefits administration, and statutory compliance reporting.The successful candidate will take the lead in organizing health and wellness programs, coordinating with healthcare...

  • Company Nurse

    1 week ago

    Makati City, National Capital Region, Philippines Lean Solutions PH Full time ₱900,000 - ₱1,200,000 per year

    Job Overview:We are seeking a dedicated and detail-oriented Occupational Health Nurse to join our team. This role is ideal for candidates with experience in workplace health management, employee medical benefits administration, and statutory compliance reporting. The successful candidate will take the lead in organizing health and wellness programs,...

  • Operations Manager – Utilization Management

    2 weeks ago

    Quezon City, National Capital Region, Philippines Nityo Infotech Full time ₱80,000 - ₱120,000 per year

    Responsibilities:Oversee daily operations and ensure compliance with SLAs and regulatory standards.Develop and implement process improvement initiatives.Manage team performance and resource allocation.Collaborate with internal and client stakeholders to enhance service delivery and maintain accurate staffing.Ensure adherence to HIPAA and other regulatory...