USRN with Prior Authorization Experience | Day 1 HMO

Optum, a UnitedHealth Group Company; Metro Manila; On-site; PHP 391,000 - 670,000; Full time

Benefits offered by this job

Total rewards package

Retirement plan

Medical plan (HMO) from Day 1

Dental & vision reimbursements

Life and disability insurance

PTO benefits

Sick leave conversion

Tuition reimbursement

EAP

Merit increases

Employee recognition

Training & staff development

Referral program

Volunteerism opportunity

Mandatory statutory benefits

Job summary

Optum Philippines in Metro Manila is seeking qualified nurses for clinical coverage review roles. Valid USRN and PHRN licenses are required, with at least 1 year of hospital bedside nursing and 1 year of prior authorization review experience. Strong clinical understanding and computer navigation are essential.

Join a team that supports member care and compliance, offering a comprehensive rewards package and professional development opportunities in a global health care environment.

Qualifications

• Valid and unrestricted USRN license required.
• PHRN license required.
• At least 1 year of hospital bedside nursing experience.
• At least 1 year of Prior Authorization Review nursing experience.
• Knowledge of hospital care, care coordination, and basic computer navigation.

Responsibilities

• Perform pre-service clinical coverage reviews to determine medical appropriateness.
• Direct non-clinical research to route cases to correct health plan teams.
• Review existing clinical documentation and interpret medical records.
• Make determinations following clinical guidelines and regulatory requirements.
• Meet productivity and quality goals and document recommendations.

Skills

USRN license

PHRN license

Hospital bedside nursing

Prior Authorization Review

Clinical care coordination

Computer navigation

Tools

Electronic Health Records

Job description

ROLE AND RESPONSIBILITIES

• Function is responsible for performing pre-service clinical coverage review of services that require notification, using applicable benefit plan documents, evidence-based medical policy and nationally recognized clinical guidelines and criteria. Determines medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination.

• Conduct Non-Clinical Research to Support Determinations. Determine that the case is assigned to the appropriate team and health plan for review (e.g., Medicare, Medicaid, Commercial, Dual Special Needs Plan)

• Review Existing Clinical Documentation. Review/interpret clinical/medical records submitted from provider (e.g., office records, test results, prior operative reports)

• Make Final Determinations Based on Clinical and Departmental Guidelines. Understand and adhere to applicable legal/regulatory requirements (e.g., federal/state requirements, HIPAA, CMS, NCQA/URAC accreditation)

• Achieve and Maintain Established Productivity and Quality Goals. Adhere to relevant quality audit standards in performing reviews, making determinations and documenting recommendations.

Your role is critical in allowing our members, families, facilities and health professionals to have greater confidence in the exceptional care we provide. And for you, an everyday opportunity to do your life's best work.SM.

JOB QUALIFICATIONS

• Valid and unrestricted USRN and PHRN licenses are required

• A minimum of 1 year of hospital bedside nursing experience is required

• At least 1 year of Prior Authorization Review Nurse experience is required

• Clinical competence in understanding hospital care and care coordination

• Knowledge in computer navigation

WHAT WE OFFER

• Market Total Rewards Package

• Retirement Plan

• Medical Plan (HMO) from Day 1 of employment

• Dental, Medical, and Optical Reimbursements

• Life and Disability Insurance

• Paid Time-Off Benefits

• Sick Leave Conversion

• Tuition Fee Reimbursement

• Employee Assistance Program (EAP)

• Annual Performance Based Merit Increases

• Employee Recognition

• Training and Staff Development

• Employee Referral Program

• Employee Volunteerism Opportunity

• All Mandatory Statutory Benefits

WHO WE ARE

• Optum is the health care technology and innovation company of the UnitedHealth Group enterprise along with UnitedHealthcare.

• UnitedHealth Group is a health care and well-being company with a mission to help people live healthier lives and help make the health system work better for everyone.

• We're a leading health solution and care delivery organization. Our work is complex, but our mission is simple: create a healthier world, with you at the center.

• As part of a Fortune 5 enterprise, we are improving the health care experience of over 125 million people around the world.

• Elevate your career with a leading health care company while improving lives.

Join us in evolving health care so everyone can have the opportunity to live their healthiest life. This is your opportunity to be part of a team that's dedicated to Caring. Connecting. Growing together