UM Nurse Specialist: Prior Authorization & Care Coordination

TP Systems; Philippines; In loco; PHP 900.000 - 1.300.000; Tempo pieno

Vantaggi offerti da questo lavoro

Onsite work at TP Vertis North

US day shift

Healthcare benefits

Descrizione del lavoro

TP Systems is seeking a Clinical Utilization Management Nurse Specialist (USRN) to join our onsite team at TP Vertis North. The role focuses on reviewing prior authorizations and concurrent reviews against clinical guidelines within a US managed care framework.

You will coordinate with providers and internal teams, escalate complex cases to Medical Directors, and support discharge planning and transfer workflows.

Competenze

• Graduate of an accredited School of Nursing; BSN.
• Active USRN license (NCLEX-passed), non-restricted.
• 1 year clinical experience plus 1 year in UM (preferred) or 2 years in UM (preferred).
• Knowledge of Medicare/Medicaid and managed care fundamentals.

Mansioni

• Review prior authorization and concurrent requests for medical necessity and level of care.
• Coordinate with providers and internal teams for timely case resolution.
• Escalate cases requiring higher-level review to Medical Directors.
• Support discharge planning and transfer authorization workflows (for concurrent).
• Document clinical information accurately and in compliance with standards.
• Provide utilization process guidance to providers and internal teams.

Conoscenze

USRN license

Clinical nursing

Analytical skills

Documentation

Communication

Onsite/Hybrid setup

Formazione

BSN

Strumenti

InterQual/MCG criteria

Descrizione del lavoro

TP Systems is seeking a Clinical Utilization Management Nurse Specialist (USRN) to join our onsite team at TP Vertis North. The role focuses on reviewing prior authorizations and concurrent reviews against clinical guidelines within a US managed care framework.

You will coordinate with providers and internal teams, escalate complex cases to Medical Directors, and support discharge planning and transfer workflows.