Remote Utilization Review Nurse: UM & Care Coordination

Omega Healthcare Management Services Pvt. Ltd.; Metro Manila; Remote; PHP 380,000 - 700,000; Full time

Job summary

Omega Healthcare Management Services is seeking a Utilization Review Nurse for a full-time remote role.

You will evaluate medical necessity, appropriateness, and efficiency of healthcare services using clinical criteria and payer guidelines, review medical records, perform concurrent and retrospective reviews, and collaborate with providers, care teams, and payers to ensure high-quality, cost-effective care.

Qualifications

• Strong utilization management skills with pre-authorization, concurrent and retrospective review experience.
• Background in discharge planning and care coordination across multidisciplinary teams.
• Clinical expertise in medicine and nursing with a current, unrestricted RN license in good standing.
• Proficiency in reviewing and interpreting medical records and clinical guidelines.
• Familiarity with payer rules, managed care principles, CMS requirements.

Responsibilities

• Review medical records and documentation to determine medical necessity and appropriateness.
• Perform concurrent and retrospective utilization reviews.
• Collaborate with providers, care teams, and payers to ensure timely, cost-effective, quality care.
• Support discharge planning and care coordination; escalate complex cases as needed.
• Document all activities accurately and maintain regulatory compliance.

Skills

Utilization management

Pre-authorization

Concurrent review

Retrospective review

Discharge planning

Care coordination

Medical record review

CMS & payer rules

Clinical documentation

Remote work

Education

RN license (unrestricted)

Tools

Electronic Health Records (EHR)

Job description

Omega Healthcare Management Services is seeking a Utilization Review Nurse for a full-time remote role.

You will evaluate medical necessity, appropriateness, and efficiency of healthcare services using clinical criteria and payer guidelines, review medical records, perform concurrent and retrospective reviews, and collaborate with providers, care teams, and payers to ensure high-quality, cost-effective care.