Clinical Utilization Management Nurse Specialist (USRN)

TP Systems; Philippines; In loco; PHP 900.000 - 1.300.000; Tempo pieno

Vantaggi offerti da questo lavoro

Onsite work at TP Vertis North

US day shift

Healthcare benefits

Descrizione del lavoro

TP Systems is seeking a Clinical Utilization Management Nurse Specialist (USRN) to join our onsite team at TP Vertis North. The role focuses on reviewing prior authorizations and concurrent reviews against clinical guidelines within a US managed care framework.

You will coordinate with providers and internal teams, escalate complex cases to Medical Directors, and support discharge planning and transfer workflows.

Competenze

• Graduate of an accredited School of Nursing; BSN.
• Active USRN license (NCLEX-passed), non-restricted.
• 1 year clinical experience plus 1 year in UM (preferred) or 2 years in UM (preferred).
• Knowledge of Medicare/Medicaid and managed care fundamentals.

Mansioni

• Review prior authorization and 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

USRN license

Clinical nursing

Analytical skills

Documentation

Communication

Onsite/Hybrid setup

Formazione

BSN

Strumenti

InterQual/MCG criteria

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.