RN Utilization Management Specialist

HealthEdge; Taguig; Remote; PHP 500,000 - 750,000; Full time

Job summary

HealthEdge is seeking a USRN Utilization Management professional in Taguig, Philippines. The role focuses on prospective, concurrent, and retrospective reviews to ensure medical necessity and appropriate care levels, with coordination across care teams and discharge planning.

Ideal candidates have an active US RN license, 3+ years of clinical nursing, and 2+ years in US healthcare utilization management, plus familiarity with HRCM or Guiding Care systems.

Qualifications

• Registered Nurse with current, unrestricted US RN license.
• 3+ years of direct, clinical nursing experience.
• 2+ years of US Healthcare experience in 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, appropriate length of stay, intensity of service, and level of care, including appeals.
• Review, research, and prepare documentation related to retrospective review requests and appeals per regulatory and accreditation standards.
• Coordinate with medical and support personnel to identify and recommend alternative treatment plans.
• Follow out-of-area/out-of-network services and recommend in-network transfers or alternative plans of care.
• Establish care plans and coordinate care through the healthcare continuum including patient outreach assessments.
• Coordinate discharge planning and communicate needs with internal and external entities.
• Review patterns of care related to disease progression and organize delivery through appropriate channels.
• Resolve issues related to benefits, member eligibility, and care coordination as needed.
• Develop and deliver targeted education for providers related to policies and benefits.

Skills

Clinical nursing experience

Utilization management

US Healthcare experience

Nurse license

Education

BSN or equivalent nursing degree

Tools

HealthEdge HRCM

Guiding Care

MCG Certification

Job description

HealthEdge is seeking a USRN Utilization Management professional in Taguig, Philippines. The role focuses on prospective, concurrent, and retrospective reviews to ensure medical necessity and appropriate care levels, with coordination across care teams and discharge planning.

Ideal candidates have an active US RN license, 3+ years of clinical nursing, and 2+ years in US healthcare utilization management, plus familiarity with HRCM or Guiding Care systems.