US RN – Prior Authorization & Utilization Review

Sagility Philippines B.V Branch; Quezon City; On-site; PHP 390,600 - 613,800; Full time

Job summary

Sagility Philippines B.V Branch in Quezon City is seeking US registered nurses to join our team. The role involves documenting all activities in systems, reviewing medical cases, and ensuring the correct level of care and timely prior authorizations.

You will apply evidence-based guidelines, collaborate with Medical Directors, and help deliver cost-effective, quality care to members. This on-site position offers exposure to US healthcare processes and a dynamic, global BPM work environment.

Qualifications

• Document all activities in the appropriate system(s) on a timely basis.
• Review individual medical cases to confirm that they are getting the most appropriate care.
• Weigh the patient's situation against the policy held by the patient, the standards of the insurance company, and the costs which may be involved in treatment.
• Promote the quality and cost effectiveness of medical care by applying clinical knowledge and the appropriate application of policies and guidelines to prior authorization requests.
• Ensure that prior authorization requests are completed in a timely fashion to meet contractual requirements and that all reviews are conducted using nationally recognized and evidence-based standards.
• Evaluate the pre-service authorization request received for scheduled inpatient admissions, ambulatory surgeries, and outpatient services and out-of-network providers.
• Determine the appropriate level of care for patient stays in acute care facilities in compliance with acute care guidelines; prior authorization medical necessity review, including determination of appropriate provision of observation care, outpatient or inpatient rehabilitation services, DME, Home Health and other ancillary healthcare services in compliance with approved care guidelines.
• Perform accurate, thorough and efficient reviews of authorization requests.
• Conduct timely review of prior authorization requests, both inpatient and outpatient.
• Handle acute hospital pre-admission, skilled nursing facility, hospice and other long-term care facilities, surgical/diagnostic procedures, therapies, durable medical equipment and home care; determine utilization decisions based upon nationally recognized and evidence-based guidelines.
• Review prior authorization requests with Medical Directors as directed.

Responsibilities

• Document all activities in the appropriate system(s) on a timely basis.
• Review individual medical cases to confirm that they are getting the most appropriate care.
• Weigh the patient's situation against the policy held by the patient, the standards of the insurance company, and the costs which may be involved in treatment.
• Promote the quality and cost effectiveness of medical care by applying clinical knowledge and the appropriate application of policies and guidelines to prior authorization requests.
• Ensure that prior authorization requests are completed in a timely fashion to meet contractual requirements and that all reviews are conducted using nationally recognized and evidence-based standards.
• Evaluate the pre-service authorization request received for scheduled inpatient admissions, ambulatory surgeries, and outpatient services and out-of-network providers.
• Determine the appropriate level of care for patient stays in acute care facilities in compliance with acute care guidelines; prior authorization medical necessity review, including determination of appropriate provision of observation care, outpatient or inpatient rehabilitation services, DME, Home Health and other ancillary healthcare services in compliance with approved care guidelines.
• Perform accurate, thorough and efficient reviews of authorization requests.
• Conduct timely review of prior authorization requests, both inpatient and outpatient.
• Handle acute hospital pre-admission, skilled nursing facility, hospice and other long-term care facilities, surgical/diagnostic procedures, therapies, durable medical equipment and home care; determine utilization decisions based upon nationally recognized and evidence-based guidelines.
• Review prior authorization requests with Medical Directors as directed.

Job description

Sagility Philippines B.V Branch in Quezon City is seeking US registered nurses to join our team. The role involves documenting all activities in systems, reviewing medical cases, and ensuring the correct level of care and timely prior authorizations.

You will apply evidence-based guidelines, collaborate with Medical Directors, and help deliver cost-effective, quality care to members. This on-site position offers exposure to US healthcare processes and a dynamic, global BPM work environment.