RN - Utilization Management Specialist

HealthEdge Software, Inc.; Taguig; Hybrid; PHP 700,000 - 1,100,000; Full time

Job summary

HealthEdge Software, Inc. invites a Registered Nurse to join our USRN Utilization Management team in Taguig.

You will perform prospective, concurrent, and retrospective reviews to ensure medical necessity and appropriate care levels across inpatient and outpatient services, coordinating with clinical staff as needed. The ideal candidate has 3+ years of direct clinical nursing experience, 2+ years in US healthcare UM or case management, and may have MCG Certification or HRCM/Guiding Care

Qualifications

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

Responsibilities

• Perform prospective, concurrent, and retrospective reviews for medical necessity and appropriate level of care.
• Review documentation for retrospective requests and appeals per regulatory standards.
• Coordinate with providers and facilities to discuss alternative treatment or care levels.
• Follow out-of-area and out-of-network guidance and recommend in-network options.
• Coordinate discharge planning and care across the health care continuum as needed.

Skills

Registered Nurse

Clinical nursing

Utilization management

US healthcare

Education

RN License

Job description

HealthEdge Software, Inc. invites a Registered Nurse to join our USRN Utilization Management team in Taguig.

You will perform prospective, concurrent, and retrospective reviews to ensure medical necessity and appropriate care levels across inpatient and outpatient services, coordinating with clinical staff as needed. The ideal candidate has 3+ years of direct clinical nursing experience, 2+ years in US healthcare UM or case management, and may have MCG Certification or HRCM/Guiding Care