RN Utilization Management Specialist

HealthEdge; Philippines; Remote; PHP 600,000 - 900,000; Full time

Job summary

HealthEdge in Taguig, Philippines, seeks a USRN for utilization management to perform prospective, concurrent, and retrospective reviews across inpatient to ambulatory services. You will assess medical necessity, coordinate care plans, and ensure appropriate levels of care while collaborating with providers and facilities.

The role requires an active US RN license and at least 3 years of direct nursing experience, with 2+ years in US healthcare utilization management; MCG or Guiding Care

Qualifications

• Registered Nurse with current, unrestricted US license.
• 3+ years direct clinical nursing experience.
• 2+ years’ experience in US healthcare utilization management or case management.
• MCG Certification will be a plus.
• Healthedge HRCM or Guiding Care experience is a plus.

Responsibilities

• Perform prospective, concurrent, and retrospective reviews of inpatient, outpatient, ambulatory and ancillary services to ensure medical necessity and level of care.
• Review, research, and prepare documentation for retrospective reviews and appeals per regulatory and accreditation standards.
• Coordinate with medical staff to identify alternative treatment plans using approved protocols.
• Follow out-of-area/out-of-network services and suggest in-network options when appropriate.
• Coordinate discharge planning and communicate needs with internal and external teams.
• Identify patterns of care and organize delivery through appropriate channels.
• Resolve issues related to benefits, eligibility, and coordination of care; educate providers when needed.

Skills

USRN license

Clinical nursing

Utilization management

MCG Certification

HRCM/Guiding Care

Job description

HealthEdge in Taguig, Philippines, seeks a USRN for utilization management to perform prospective, concurrent, and retrospective reviews across inpatient to ambulatory services. You will assess medical necessity, coordinate care plans, and ensure appropriate levels of care while collaborating with providers and facilities.

The role requires an active US RN license and at least 3 years of direct nursing experience, with 2+ years in US healthcare utilization management; MCG or Guiding Care