Senior Clinical Informatics & Utilization Review Specialist

Optum, a UnitedHealth Group Company; Metro Manila; Hybrid; PHP 1,200,000 - 2,200,000; Full time

Benefits offered by this job

Market Total Rewards Package

Retirement Plan

Medical Plan (HMO) from Day 1 ofEMPLOY

Dental, Medical, and Optical Reimburse

Life and Disability Insurance

Paid Time‑Off Benefits

Sick Leave Conversion

Tuition Fee Reimbursement

Employee Assistance Program (EAP)

Annual Performance Based Merit Increas

Employee Recognition

Training and Staff Development

Employee Referral Program

Employee Volunteerism Opportunity

All Mandatory Statutory Benefits

Job summary

Optum, a UnitedHealth Group company, in the Philippines is seeking a Senior Nurse Content Developer for clinical content development and utilization review. You will lead and support projects from planning through release, coordinating with clinical leadership, physician researchers, and medical directors to ensure accurate, compliant, and timely content.

The role requires in-depth literature reviews, CDI support for DRG validation, and data‑driven content revisions.

Qualifications

• Minimum of 10 years of clinical nursing experience.
• At least 2 years of Utilization Review experience, preferably with Physician Advisor Services.
• Strong knowledge of case management, commercial insurance, Medicare processes, and patient status requirements.
• Experience with Clinical Documentation Improvement (CDI) requirements for DRG validation.
• Minimum of 2 years of clinical content development experience.
• Preferred experience with Electronic Medical Records (EMR) systems.
• Excellent communication, presentation, research, writing, project management and computer skills.

Responsibilities

• Leads and supports clinical content development projects from planning through release, including project tracking, scope management, and stakeholder coordination.
• Collaborates with Clinical Leadership, physician researchers, Clinical Managers, and Medical Directors to ensure content accuracy, compliance, consistency, and timely delivery.
• Conducts in-depth medical literature reviews, evaluates and summarizes clinical evidence, and develops comprehensive e-learning materials for physician and nursing audiences.
• Develops specialized appeals arguments related to patient status, DRG validation, and CDI requirements using medical evidence and payer-specific outcomes.
• Applies risk factor logic, decision‑making frameworks, and SQL‑based validation to ensure content quality and alignment across Optum Clinical Groups and InterQual products.
• Analyzes medical claims and denials data, identifies trends, categorizes cases, develops analytical frameworks, and recommends content revisions based on data-driven insights.
• Reviews complex medical records, supports AI-assisted clinical research workflows, provides ad hoc analytics and case reviews.

Skills

Clinical nursing

Utilization Review

Case management

CDI

EMR experience

Communication skills

Project management

Data analysis

Tools

EMR systems

Job description

Optum, a UnitedHealth Group company, in the Philippines is seeking a Senior Nurse Content Developer for clinical content development and utilization review. You will lead and support projects from planning through release, coordinating with clinical leadership, physician researchers, and medical directors to ensure accurate, compliant, and timely content.

The role requires in-depth literature reviews, CDI support for DRG validation, and data‑driven content revisions.