USRN — Utilization Management

HealthEdge; Philippines; Remote; PHP 450,000 - 650,000; Full time

Job summary

HealthEdge in the Philippines is hiring a clinical reviewer to evaluate medical necessity and determine appropriate level of care across inpatient, ambulatory, and ancillary services. You will review requests, prepare documentation, and support appeals for providers, facilities, and members.

The role requires an active, unrestricted RN license with at least two years of bedside nursing experience, plus one year in health plans or HMOs and familiarity with Medicare policy.

Qualifications

• Active, unrestricted RN license required, 2+ years of bedside nursing experience preferred.
• 1+ year of health plan or HMO experience.
• Experience in Medicare policy

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 clinical protocols
• Review outpatient network services and recommend transfers to in-network care
• Establish care and coordinate care through the health care continuum
• Coordinate discharge with inpatient and other entities
• Research and resolve issues on benefits, eligibility, and coordination of benefits
• Develop and deliver provider education on policies, procedures

Skills

Care coordination

Documentation

Regulatory compliance

Medical terminology

Communication

Education

RN license

Job description

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