USRN Utilization Management Nurse | UM Expert

Genfinity Philippines, Inc.; Philippines; On-site; PHP 446,000 - 781,000; Full time

Job summary

Genfinity Philippines, Inc. is seeking a USRN to join its Philippine-based site to provide utilization management services for clients, insurers, and injured employees.

The role supports cost-effective, quality medical care and requires active nursing licensure in the Philippines and US, with at least one year in utilization management. The successful candidate will gather medical data, review treatment necessity, and ensure timely processing of billings, referrals, and assessments.

Qualifications

• Active nursing license in the Philippines and in the mainland US.
• One year of experience in Utilization Management/Review.
• Demonstrated knowledge of ICD-10 codes, utilization review process, and criteria.
• Excellent verbal and written communication, organizational, and leadership skills.
• Proficiency in MS Word and Excel and general computer literacy, working with dual screens.
• Strong analytical, interpersonal, and time management skills.

Responsibilities

• Facilitate verbal and written communication with employees, employers, providers of care, and adjusters.
• Gather medical data to evaluate the necessity of medical treatment and functional capabilities.
• Insure timely processing of billings, utilization issues, and/or referral decisions.
• Resolve, negotiate, and make recommendations regarding medical care.
• Compare medical information to establish criteria and determine appropriateness of treatment and length of treatment.
• Determine appropriateness of referrals to peer advisors.
• Maintain and monitor volume and cost of peer advisor reviews for management report.
• Perform and maintain research, documentation, statistics, and auditing information on all types of medical providers, procedures, scopes of practice, and professional organizations.
• Respond promptly and expertly to inquiries from providers and UM staff.
• Function as a resource to medical audit, other UM staff, customers, and outside agencies.
• Assist claims professional in compensability issues involving ICD-10 codes and treatment parameters.
• Provide appropriate reports to management reflecting activities and results.
• Review application for patient admission and approve admission or refer case for peer review when standards aren’t met.
• Attend training/educational classes as appropriate.
• Coordinate activities of staff in supervisor’s absence.
• Participate in QM monitoring and meet departmental standards and objectives.
• Perform other duties as assigned.

Skills

Active Nursing license

Utilization Management

ICD-10 knowledge

Verbal and written communication

MS Word & Excel

Time management

Education

Nursing degree

Tools

MS Word

Excel

Job description

Genfinity Philippines, Inc. is seeking a USRN to join its Philippine-based site to provide utilization management services for clients, insurers, and injured employees.

The role supports cost-effective, quality medical care and requires active nursing licensure in the Philippines and US, with at least one year in utilization management. The successful candidate will gather medical data, review treatment necessity, and ensure timely processing of billings, referrals, and assessments.