US Registered Nurse

PM Consulting; Metro Manila; On-site; PHP 360,000 - 600,000; Full time

Job summary

PM Consulting is seeking a US Registered Nurse (USRN) to support clinical review and healthcare operations from the Philippines. The role focuses on evaluating medical records, validating clinical necessity, and ensuring payer and regulatory compliance to drive accurate reimbursement outcomes.

You will conduct utilization review, prior authorizations, and collaborative case assessments while maintaining productivity and quality metrics in a fast-paced environment.

Qualifications

• Active and unrestricted US RN license is required.
• BSN degree is preferred.
• 3 years of bedside ICU/ER/Med-Surg experience.
• Strong knowledge of US healthcare system, payer guidelines, and clinical standards.
• Excellent clinical judgment, analytical thinking and documentation skills.
• Ability to work in a fast-paced, performance-driven environment.

Responsibilities

• Conduct utilization review and evaluate medical necessity using established criteria.
• Review patient medical records to assess level of care and services.
• Ensure adherence to payer policies and CMS regulations.
• Perform prior authorization, concurrent review, and other utilization management activities.
• Support denial management with clinical recommendations for appeals.
• Collaborate with providers and cross-functional teams to resolve documentation gaps.
• Maintain productivity and quality metrics based on targets.
• Document review findings in designated clinical systems.
• Stay updated on US healthcare regulations and payer requirements.

Skills

Clinical judgment

Analytical thinking

Documentation skills

Provider collaboration

Education

RN license (unrestricted)

BSN preferred

Job description

The US Registered Nurse (USRN) will support clinical review and healthcare operations by evaluating medical records, validating clinical necessity, and ensuring compliance with payer and regulatory standards. This role focuses on supporting accurate reimbursement outcomes through clinical documentation review, utilization management, and collaborative case assessment.

Key Responsibilities

• Conduct utilization review and evaluate medical necessity using established clinical criteria and guidelines.

• Review patient medical records to assess level of care, treatment plans, and medical services rendered.

• Ensure adherence to payer policies, CMS regulations, and healthcare industry standards.

• Perform prior authorization, concurrent review, and other utilization management activities as required.

• Support denial management by reviewing clinical cases and providing appeal-related clinical recommendations.

• Collaborate with providers, clinicians, and cross-functional teams to resolve documentation gaps.

• Maintain productivity, quality, and performance metrics based on operational targets.

• Document review findings accurately in designated clinical systems and platforms.

• Stay updated on current US healthcare regulations, payer requirements, and clinical practice standards.

Qualifications

• Active and unrestricted US Registered Nurse (RN) license (required).

• Bachelor of Science in Nursing (BSN) preferred.

• 3 years of bedside experience in ICU, ER, Medical-Surgical setting.

• Strong knowledge of the US healthcare system, clinical standards, and payer guidelines.

• Excellent clinical judgment, analytical thinking, and documentation skills.

• Ability to work in a fast-paced, performance-driven environment.

Preferred Experience

• Experience supporting US payer or provider healthcare accounts.

• Familiarity with clinical decision support tools such as InterQual, MCG, or similar platforms.

• Background in denial management or clinical documentation review.

• Experience in healthcare BPO, shared services, or outsourcing environments.