Clinical Utilization Review Nurse

Optum, a UnitedHealth Group Company; Metro Manila; Vor Ort; PHP 600.000 - 900.000; Vollzeit

Benefits dieser Stelle

Total Rewards

Retirement Plan

Healthcare from Day 1

Dental & Vision

Life & Disability

Paid Time Off

Sick Leave Exchange

Tuition Reimbursement

EAP

Merit Increases

Employee Recognition

Training & Development

Referral Program

Volunteer Program

Statutory Benefits

Zusammenfassung

Optum is hiring a clinical reviewer in Metro Manila to perform pre-service coverage reviews of inpatient and outpatient services, using benefit documents, evidence-based medical policy, and recognized guidelines. The role ensures medical appropriateness and regulatory compliance for both inpatient and outpatient determinations.

The position requires USRN and PHRN licenses and a minimum of 2 years hospital bedside experience (ICU/ER/Medical-Surgical/CCU).

Qualifikationen

• Valid and unrestricted USRN and PHRN Licenses required.
• Must have a minimum of 2 years hospital bedside experience (ICU, ER, Medical Surgical, CCU).
• Clinical competence in understanding hospital care and care coordination.
• Knowledge in computer navigation.

Aufgaben

• Perform pre-service clinical coverage review of services to determine medical appropriateness.
• Conduct non-clinical research to support determinations and route cases to appropriate teams.
• Review existing clinical documentation and interpret medical records for review.
• Make final determinations based on clinical guidelines and regulatory requirements (HIPAA, CMS, NCQA/URAC).
• Achieve and maintain productivity and quality goals by following audit standards.

Kenntnisse

USRN/PHRN licenses

Hospital bedside experience

Clinical care coordination

Computer navigation skills

Jobbeschreibung

Optum is hiring a clinical reviewer in Metro Manila to perform pre-service coverage reviews of inpatient and outpatient services, using benefit documents, evidence-based medical policy, and recognized guidelines. The role ensures medical appropriateness and regulatory compliance for both inpatient and outpatient determinations.

The position requires USRN and PHRN licenses and a minimum of 2 years hospital bedside experience (ICU/ER/Medical-Surgical/CCU).