RN - Clinical Review & Reimbursement Specialist

PM Consulting; Metro Manila; Presencial; PHP 360.000 - 600.000; Jornada completa

Descripción de la vacante

PM Consulting is seeking a US Registered Nurse (USRN) to support clinical review and healthcare operations from the Philippines. The role focuses on evaluating medical records, validating clinical necessity, and ensuring payer and regulatory compliance to drive accurate reimbursement outcomes.

You will conduct utilization review, prior authorizations, and collaborative case assessments while maintaining productivity and quality metrics in a fast-paced environment.

Formación

• Active and unrestricted US RN license is required.
• BSN degree is preferred.
• 3 years of bedside ICU/ER/Med-Surg experience.
• Strong knowledge of US healthcare system, payer guidelines, and clinical standards.
• Excellent clinical judgment, analytical thinking and documentation skills.
• Ability to work in a fast-paced, performance-driven environment.

Responsabilidades

• Conduct utilization review and evaluate medical necessity using established criteria.
• Review patient medical records to assess level of care and services.
• Ensure adherence to payer policies and CMS regulations.
• Perform prior authorization, concurrent review, and other utilization management activities.
• Support denial management with clinical recommendations for appeals.
• Collaborate with providers and cross-functional teams to resolve documentation gaps.
• Maintain productivity and quality metrics based on targets.
• Document review findings in designated clinical systems.
• Stay updated on US healthcare regulations and payer requirements.

Conocimientos

Clinical judgment

Analytical thinking

Documentation skills

Provider collaboration

Educación

RN license (unrestricted)

BSN preferred

Descripción del empleo

PM Consulting is seeking a US Registered Nurse (USRN) to support clinical review and healthcare operations from the Philippines. The role focuses on evaluating medical records, validating clinical necessity, and ensuring payer and regulatory compliance to drive accurate reimbursement outcomes.

You will conduct utilization review, prior authorizations, and collaborative case assessments while maintaining productivity and quality metrics in a fast-paced environment.