US Registered Nurse

PM Consulting; Taguig; In loco; PHP 1.823.000 - 2.664.000; Tempo pieno

Descrizione del lavoro

PM Consulting in the Philippines seeks a highly skilled US Registered Nurse (USRN) to support clinical review, nurse auditing, utilization review, and medical bill review.

The ideal candidate has surgical hospital or clinical case management experience, plus hands-on work in nurse auditing and billing review, and strong clinical judgment.

Competenze

• Must be a US Registered Nurse (USRN) with an active US license.
• Minimum 2 years of recent surgical hospital experience or 2+ years in clinical case management.
• Experience in complex medical, legal, and consultation review is preferred.
• At least 2 years applying nurse auditing, utilization review, and medical bill review.
• Strong clinical assessment, analytical skills, and ability to interpret medical records.

Mansioni

• Conduct clinical review and analysis of medical records and treatment plans for necessity and compliance.
• Perform nurse auditing, utilization review, and medical bill review daily.
• Identify discrepancies, overutilization, and billing concerns for cost containment.
• Apply nursing judgment to complex medical and surgical cases.
• Review and validate bills and documentation for accuracy and consistency.
• Collaborate with physicians, nurses, case managers, and other stakeholders.
• Support complex medical, legal, and consultation reviews when applicable.
• Ensure complete documentation of findings, recommendations, and decisions.
• Escalate cases requiring further clinical or management review.
• Maintain confidentiality and comply with healthcare policies and standards.
• Meet productivity, quality, turnaround time, and accuracy targets.
• Stay updated on guidelines and utilization management practices.
• Perform other clinical review, auditing, and utilization management duties.

Conoscenze

Clinical assessment

Critical thinking

Attention to detail

Written & verbal comms

Independent work

Team collaboration

Formazione

Active US nursing license

Descrizione del lavoro

We are looking for a highly skilled and detail-oriented US Registered Nurse (USRN) to support clinical review, nurse auditing, utilization review, and medical bill review activities. The role requires strong clinical judgment and the ability to assess medical records, treatment plans, and healthcare services against established clinical and utilization guidelines.

The ideal candidate has recent surgical hospital experience or clinical case management experience, combined with hands-on experience in nurse auditing, utilization review, and bill review.

Key Responsibilities

• Conduct clinical review and analysis of medical records, treatment plans, and healthcare services to determine medical necessity, appropriateness, and compliance with established guidelines.
• Perform nurse auditing, utilization review, and medical bill review activities on a daily basis.
• Review medical documentation and identify discrepancies, potential overutilization, coding or billing concerns, and opportunities for cost containment.
• Apply clinical knowledge and professional nursing judgment when evaluating complex medical and surgical cases.
• Conduct case reviews and provide appropriate recommendations based on clinical findings and established review criteria.
• Review and validate medical bills and supporting documentation for accuracy, appropriateness, and consistency with services rendered.
• Collaborate with physicians, nurses, case managers, claims professionals, and other healthcare stakeholders as required.
• Support complex medical, legal, and consultation reviews when applicable.
• Ensure accurate and complete documentation of clinical review findings, recommendations, and decisions.
• Identify potential quality, utilization, or compliance issues and escalate cases requiring further clinical or management review.
• Maintain confidentiality and ensure compliance with applicable healthcare policies, standards, and regulatory requirements.
• Meet established productivity, quality, turnaround time, and accuracy targets.
• Stay updated on clinical guidelines, utilization management standards, and relevant healthcare practices.
• Perform other clinical review, auditing, and utilization management responsibilities as assigned.

Qualifications

• Must be a US Registered Nurse (USRN) with an active and unrestricted US nursing license.
• At least 2 years of recent surgical experience in a hospital setting is required, OR 2+ years of clinical case management experience.
• Experience in complex medical, legal, and consultation review is highly preferred.
• At least 2 years of experience in the daily application of nurse auditing, utilization review, and medical bill review.
• Strong clinical assessment and critical-thinking skills.
• Ability to interpret and analyze medical records and clinical documentation.
• Strong understanding of healthcare delivery, medical terminology, and clinical processes.
• Excellent written and verbal communication skills.
• Strong attention to detail and ability to make sound clinical decisions.
• Ability to work independently while effectively collaborating with cross-functional teams.
• Experience supporting US healthcare operations or US healthcare clients is an advantage.
• Willing to work on night shifts, weekends, and holidays depending on business requirements.