USRN Associates

Create Synergies Inc.; Manila; On-site; PHP 670,000 - 1,004,000; Full time

Job summary

Create Synergies Inc. in the Philippines seeks a US Registered Nurse (USRN) to 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 contributing to accurate reimbursement outcomes through clinical documentation review, utilization management, and collaborative case assessment, while staying current on US healthcare regulations and payer requirements.

Qualifications

• Active US RN license (required).
• BSN preferred.
• 3 years bedside ICU/ER/Medical-Surgical 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 records to assess level of care and services rendered.
• Ensure adherence to payer policies, CMS regulations, and industry standards.
• Perform prior authorization, concurrent review, and other utilization management tasks.
• Support denial management with evidence-based clinical recommendations.
• Collaborate with providers and teams to resolve documentation gaps.
• Maintain productivity and quality metrics against targets.
• Document review findings in clinical systems accurately.
• Stay updated on US healthcare regulations and payer requirements.

Skills

Clinical review

Utilization management

Documentation skills

Analytical thinking

Clinical judgment

Fast-paced work ethic

Education

BSN degree

US RN license required

Tools

InterQual

MCG

Job description

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.