Clinical Utilization Management Nurse Specialist (USRN)

TP; Quezon City; Hybrid; PHP 670,000 - 1,004,000; Full time

Job summary

TP is seeking a Clinical Review Nurse to evaluate prior authorization and concurrent review requests against guidelines for a US managed care environment. You will work to ensure timely, cost-effective care delivery and collaborate with providers and internal teams for resolution.

Required BSN with 1 year of clinical experience and 1 year in UM (preferred) or 2 years in UM/Prior Authorization. Familiarity with InterQual/MCG is a plus; position supports onsite/hybrid setups.

Qualifications

• Graduate of an accredited School of Nursing; BSN.
• 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.

Responsibilities

• 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.

Skills

Analytical skills

Documentation

Communication

Education

BSN

Tools

InterQual

MCG

Job description

• 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
• 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.