Team Lead, USRN Utilization Review

Private Advertiser; Taguig; On-site; PHP 900,000 - 1,300,000; Full time

Job summary

Private Advertiser in the Philippines is seeking a lead USRN utilization review nurse to manage a team across shifts, ensuring quality, productivity, and adherence to InterQual/MCG criteria. You will coach staff, review performance, and maintain high standards of care while delivering timely decisions.

You will train staff, handle escalations and complex cases, and maintain strong client relationships, all while ensuring HIPAA compliance and regulatory requirements are met.

Qualifications

• BSN required and active US RN license.
• 3+ years of utilization review or utilization management on a US healthcare account.
• 1+ year as Team Lead or Supervisor of a clinical team.
• Strong knowledge of InterQual or MCG, prior authorization, and concurrent review.
• Clear communicator who can coach nurses and manage client relationships.

Responsibilities

• Lead, coach, and supervise a team of USRN utilization review nurses.
• Monitor daily productivity, turnaround times, and quality scores, and take action when targets slip.
• Audit reviews for accurate application of InterQual or MCG criteria and medical necessity decisions.
• Handle escalations, complex cases, and referrals for physician or peer-to-peer review.
• Train new hires and run ongoing refreshers on criteria, payer guidelines, and process updates.
• Manage schedules, attendance, and workload distribution across shifts.
• Prepare performance reports and lead regular calls with the client.
• Ensure the team follows HIPAA and all compliance requirements.

Skills

Leadership

Coaching

Communication

Nursing knowledge

HIPAA compliance

Education

BSN

Tools

InterQual/MCG

Prior Authorization

Concurrent Review

Job description

About the role

Lead, coach, and supervise a team of USRN utilization review nurses. Monitor daily productivity, turnaround times, and quality scores, and take action when targets slip. Audit reviews for accurate application of InterQual or MCG criteria and medical necessity decisions. Handle escalations, complex cases, and referrals for physician or peer-to-peer review. Train new hires and run ongoing refreshers on criteria, payer guidelines, and process updates. Manage schedules, attendance, and workload distribution across shifts. Prepare performance reports and lead regular calls with the client. Make sure the team follows HIPAA and all compliance requirements.

Key responsibilities

• Lead, coach, and supervise a team of USRN utilization review nurses
• Monitor daily productivity, turnaround times, and quality scores, and take action when targets slip
• Audit reviews for accurate application of InterQual or MCG criteria and medical necessity decisions
• Handle escalations, complex cases, and referrals for physician or peer-to-peer review
• Train new hires and run ongoing refreshers on criteria, payer guidelines, and process updates
• Manage schedules, attendance, and workload distribution across shifts
• Prepare performance reports and lead regular calls with the client
• Ensure the team follows HIPAA and all compliance requirements

About you

• Bachelor of Science in Nursing (BSN)
• Active US RN license
• 3+ years of utilization review or utilization management experience on a US healthcare account
• 1+ year as a Team Lead or Supervisor of a clinical team
• Strong working knowledge of InterQual or MCG, prior authorization, and concurrent review
• Clear communicator who can coach nurses and manage client relationships