USRN Case Manager Nurse

Vee Healthtek; Philippines; On-site; PHP 4,101,000 - 6,625,000; Full time

Job summary

Vee Healthtek is seeking a highly qualified US-licensed RN with acute care bedside experience to support utilization management, prior authorization, denials management, and appeals. The role emphasizes multi-payer medical necessity reviews and strong collaboration with physicians and payers.

The candidate should be proficient in ICD-10/CPT coding, MCG/InterQual guidelines, EMR systems, and payer portals, enabling effective denials management and effective communication with care teams.

Qualifications

• Active US Registered Nurse (RN) license; New York State RN license preferred.
• Minimum 2+ years of recent bedside clinical experience in an acute care hospital setting.
• Minimum 2+ years of experience in Utilization Management (UM), Prior Authorization, Denials Management, or Appeals Review.
• Extensive experience handling inpatient medical necessity appeals across Commercial, Medicare, Medicaid, and Managed Care payers.
• Strong knowledge of inpatient authorization denials, medical necessity denials, level-of-care determinations, procedure denials, medication denials, and retrospective reviews.
• Proficient in MCG, InterQual, CMS Medicare Guidelines, and commercial payer medical policies.
• Experience with first-level appeals, second-level appeals, reconsiderations, Peer-to-Peer (P2P) reviews, and medical necessity appeal letters.
• Knowledge of medical terminology, ICD-10, CPT, and basic coding concepts.
• Excellent written and verbal communication skills with physicians, payers, case managers, and leadership teams.
• Proficient in EMR systems, Microsoft Office, payer portals, and utilization management platforms.

Skills

Active US RN license

New York State RN license preferred

Bedside acute care experience

Utilization Management

Prior Authorization

Denials Management

Appeals Review

Inpatient medical necessity appeals

Medical necessity denials knowledge

MCG InterQual CMS guidelines

Payer policies knowledge

First/Second level appeals, P2P

ICD-10 CPT coding

Communication with physicians and pay⟷

EMR systems

Microsoft Office

Payer portals

Utilization management platforms

Tools

EMR systems

Microsoft Office

Payer portals

Utilization management platforms

Job description

Qualifications and Key Requirements

• Active US Registered Nurse (RN) license; New York State RN license preferred.
• Minimum 2+ years of recent bedside clinical experience in an acute care hospital setting.
• Minimum 2+ years of experience in Utilization Management (UM), Prior Authorization, Denials Management, or Appeals Review.
• Extensive experience handling inpatient medical necessity appeals across Commercial, Medicare, Medicaid, and Managed Care payers.
• Strong knowledge of inpatient authorization denials, medical necessity denials, level-of care determinations, procedure denials, medication denials, and retrospective reviews.
• Proficient in MCG, InterQual, CMS Medicare Guidelines, and commercial payer medical policies.
• Experience with first-level appeals, second-level appeals, reconsiderations, Peer-to-Peer (P2P) reviews, and medical necessity appeal letters.
• Knowledge of medical terminology, ICD-10, CPT, and basic coding concepts.
• Excellent written and verbal communication skills with physicians, payers, case managers, and leadership teams.
• Proficient in EMR systems, Microsoft Office, payer portals, and utilization management platforms.