RN Utilization Review Specialist - Night Shift (Onsite)

PM Consulting; Cebu City; On-site; PHP 420,000 - 660,000; Full time

Job summary

PM Consulting is seeking an USRN Utilization Review Specialist to review clinical information, medical records, and patient cases to determine medical necessity and appropriate level of care. The role collaborates with physicians, payers, and internal teams, applying InterQual/MCG criteria and ensuring HIPAA compliance.

Responsibilities include inpatient/outpatient reviews, documentation, and communicating decisions. Night shifts and onsite work may be required depending on the account.

Qualifications

• Must be a Registered Nurse (RN) in the Philippines.
• Preferably with a valid and active USRN license.
• 2–3 years of clinical experience in hospital, utilization management, or related areas.
• Experience with US healthcare or utilization review is an advantage.
• Familiarity with InterQual, MCG, or other guidelines is preferred.
• Strong communication and documentation skills in English.

Responsibilities

• Conduct utilization review of inpatient and/or outpatient cases to determine medical necessity and appropriateness of services.
• Review medical records, clinical documentation, treatment plans, and other relevant patient information.
• Apply clinical criteria and evidence-based guidelines such as InterQual or MCG.
• Determine level of care, length of stay, and continued stay based on the patient’s condition.
• Collaborate with physicians, nurses, case managers, and other healthcare professionals on utilization decisions.
• Perform concurrent, retrospective, and prospective reviews as assigned.
• Facilitate peer-to-peer discussions when required.
• Communicate authorization decisions and clinical recommendations professionally.
• Identify overutilization/underutilization and opportunities for resource optimization.
• Ensure reviews and documentation meet turnaround times and regulatory standards.

Skills

RN license (Philippines)

USRN license preferred

2–3 years clinical experience

Clinical criteria knowledge (InterQual

English communication

HIPAA compliance

EMR / EHR systems

Education

Nursing degree (Philippines)

Tools

EMR/EHR software

Job description

PM Consulting is seeking an USRN Utilization Review Specialist to review clinical information, medical records, and patient cases to determine medical necessity and appropriate level of care. The role collaborates with physicians, payers, and internal teams, applying InterQual/MCG criteria and ensuring HIPAA compliance.

Responsibilities include inpatient/outpatient reviews, documentation, and communicating decisions. Night shifts and onsite work may be required depending on the account.