Clinical Utilization Management Nurse Specialist (USRN)

Rouxel TP; Philippines; In loco; PHP 480.000 - 720.000; Tempo pieno

Descrizione del lavoro

ROUXEL TP is seeking a Clinical Utilization Management Nurse Specialist (USRN) to review prior authorization and concurrent requests against clinical guidelines within a US managed care setting. The role is onsite at TP Vertis North with US daytime hours.

Responsibilities include coordinating with providers, escalating cases to Medical Directors, supporting discharge planning, and ensuring accurate documentation.

Competenze

• Graduate of an accredited School of Nursing; BSN
• Active USRN license (NCLEX-passed), non-restricted
• 1-year clinical experience (hospital, clinic, or academe) plus 1 year in UM (Prior Authorization, or Concurrent Review - preferred) or 2 years in UM, Prior Authorization, or Concurrent Review - preferred
• Knowledge of Medicare/Medicaid and managed care fundamentals
• Strong analytical, documentation, and communication skills
• Amenable to US shift and onsite/hybrid setup

Mansioni

• Review prior authorization and/or concurrent requests for medical necessity and level of care
• Coordinate with providers and internal teams for timely case resolution
• Escalate cases requiring higher-level review to Medical Directors
• Support discharge planning and transfer authorization workflows (for concurrent)
• Document clinical information accurately and in compliance with standards
• Provide utilization process guidance to providers and internal teams

Conoscenze

Analytical skills

Documentation skills

Communication skills

USRN license

Formazione

BSN

Strumenti

InterQual

MCG

Descrizione del lavoro

Clinical Utilization Management Nurse Specialist (USRN)

• Work Arrangement: Onsite (TP Vertis North)
• Schedule: US Day Shift

Use your clinical expertise to review prior authorization and or concurrent review requests against clinical guidelines and ensure members receive appropriate, timely, and cost-effective care within a US managed care environment.

What You'll Do

• Review prior authorization and or concurrent requests for medical necessity and level of care.
• Coordinate with providers and internal teams for timely case resolution.
• Escalate cases requiring higher-level review to Medical Directors.
• Support discharge planning and transfer authorization workflows (for concurrent)
• Document clinical information accurately and in compliance with standards.
• Provide utilization process guidance to providers and internal teams.

What You Need

• Graduate of an accredited School of Nursing; BSN
• Active USRN license (NCLEX-passed), non-restricted
• 1-year clinical experience (hospital, clinic, or academe) plus 1 year in UM (Prior Authorization, or Concurrent Review - preferred); or 2 years in UM, Prior Authorization, or Concurrent Review - preferred
• Knowledge of Medicare/Medicaid and managed care fundamentals.
• Strong analytical, documentation, and communication skills.
• Amenable to US shift and onsite/hybrid setup.

Preferred

• Healthcare BPO or payer experience.
• Familiarity with InterQual, MCG, or similar criteria tools.