USRN Utilization Review Nurse — Night Shift

Our Clients; Cebu City; On-site; PHP 600,000 - 900,000; Full time

Job summary

Our Clients in Cebu, Philippines seeks an USRN Utilization Review Specialist to review clinical information and determine medical necessity per guidelines and payer requirements. You will collaborate with physicians, nurses, and care teams to support appropriate utilization while ensuring compliance with regulatory standards.

The role requires evaluating inpatient/outpatient cases, applying InterQual/MCG criteria, and determining level of care, length of stay, and continued stay.

Qualifications

• Must be a Registered Nurse (RN) in the Philippines.
• Preferably with a valid and active USRN license.
• 2–3 years of clinical experience in hospital, utilization management, or related settings.
• Experience with US healthcare or payer criteria is advantageous.
• Familiarity with InterQual/MCG or similar guidelines is preferred.

Responsibilities

• Conduct utilization review of inpatient and/or outpatient cases to determine medical necessity and appropriateness of services.
• Review medical records, clinical documentation, treatment plans, and other relevant patient information.
• Apply clinical criteria and guidelines such as InterQual, MCG, or other payer-specific criteria.
• Determine level of care, length of stay, continued stay based on clinical condition.
• Collaborate with physicians, nurses, case managers, and other healthcare professionals regarding utilization decisions.
• Perform concurrent, retrospective, and/or prospective reviews.
• Facilitate physician-to-physician or peer-to-peer discussions.
• Communicate authorization decisions and clinical recommendations accurately.
• Identify overutilization, underutilization, and gaps in care and opportunities for resource utilization.
• Ensure reviews and documentation completed accurately within turnaround times.
• Maintain compliance with HIPAA, payer policies, regulatory requirements, and standards.
• Document clinical findings, outcomes, and recommendations in systems.
• Meet productivity, quality, and turnaround-time targets.
• Participate in audits, calibration sessions, training, and process improvement.

Skills

Verbal and written English

Critical-thinking

Documentation

Education

Registered Nurse (RN) license Philippines

USRN license (active)

Tools

EMR systems

Job description

Our Clients in Cebu, Philippines seeks an USRN Utilization Review Specialist to review clinical information and determine medical necessity per guidelines and payer requirements. You will collaborate with physicians, nurses, and care teams to support appropriate utilization while ensuring compliance with regulatory standards.

The role requires evaluating inpatient/outpatient cases, applying InterQual/MCG criteria, and determining level of care, length of stay, and continued stay.