USRN Utilization Management

Healthedge; Philippines; Remote; PHP 335,000 - 670,000; Full time

Job summary

Healthedge is seeking a healthcare reviewer to conduct prospective, concurrent, and retrospective reviews ensuring medical necessity, appropriate length of stay, and level of care. This role handles appeal requests from providers, facilities, and members.

The position supports remote work with occasional onsite duties for equipment setup, and requires experience with Medicare policy and clinical protocols to guide treatment decisions and care coordination.

Qualifications

• Active, unrestricted LJSRN license required, 2+ years of experience; bedside nursing experience preferred.
• 1+ year of health plan or ODM experience.
• Experience in Medicare policy.
• Experience in MCG preferred.
• HealthEdge HRCM or Guiding Care experience a plus.

Responsibilities

• Review inpatient, ambulatory, and ancillary services for medical necessity and level of care.
• Prepare documentation for retrospective reviews and appeals per regulatory and NCQA standards.
• Recommend treatment, service levels, or length of stay using approved clinical protocols.
• Review out-of-network services and recommend transfers to in-network care.
• Establish care and coordinate care through the health care continuum.
• Coordinate discharge with internal teams and entities.
• Research and resolve issues on benefits, eligibility, and coordination of benefits.
• Develop and deliver provider education on policies and procedures.

Skills

Nursing license (LJSRN)

Bedside nursing experience

Medicare policy knowledge

MCG experience

HealthEdge HRCM/Guiding Care

Health plan experience

Job description

SCHEDULE

Night Shift

WORK SETUP

Full Remote — Day I onsite for equipment setLw; occasional onsite work as Backup internet required; laptop provided.

ROLE OVERVIEW

Perform prospective, concurrent, and retrospective reviews of care to ensure medical necessity, appropriate length of stay and level of care, including appeal requests from providers, facilities, and members.

KEY RESPONSIBILITIES

• Review inpatient, ambulatory, and ancillary services for medicd necessity and level of care
• PrepMe documentation for retrospective reviews and appeals per regulatory and NCQA standards
• Recommend treatrnent, service Evels, or length Of Stay using approved dinical protocols
• Review out-okletwork services and recornmend transfers to in- network care
• Establish care and coordinate care through the health care cmtinuum
• Chrdinate discharge With internd and entities
• Research and resolve issues on benefits, eligibity, and coordination Of benefits
• Devdop and deliver provider education on policies, procedures,

REQUIRED SKILLS & QUALIFICATIONS

• Active, unrestricted LJSRN license required 2+ years Of experience; bedside nursing experieme preferred
• 1+ year Of health plan or 0M experience
• Experience in Medicare policy
• Experience in MCG preferred
• HealthEdge HRCM Or Guiding Care experience a plus