USRN with Utilization Review Experience

Optum, a UnitedHealth Group Company; Metro Manila; On-site; PHP 1,800,000 - 2,400,000; Full time

Benefits offered by this job

Market Total Rewards Package

Retirement Plan

Medical Plan (HMO) from Day 1

Dental, Medical, and Optical Reimburse

Life and Disability Insurance

Paid Time-Off Benefits

Sick Leave Conversion

Tuition Fee Reimbursement

Employee Assistance Program (EAP)

Job summary

Optum Philippines is seeking a seasoned nursing professional to lead clinical content development projects and support utilization review processes. You will collaborate with Clinical Leadership, physician researchers, and Medical Directors to ensure accuracy, compliance, and timely delivery of e-learning materials.

The role requires deep clinical expertise, CDI familiarity, and the ability to apply decision-tree logic to content development, with data-driven insights guiding content revisions

Qualifications

• Minimum of 10 years of clinical nursing experience in hospital settings.
• At least 2 years of Utilization Review experience, preferably with Physician Advisor Services.
• Strong knowledge of case management, commercial insurance, Managed Medicare, Traditional Medicare processes.
• Experience with CDI requirements to support DRG validation and research initiatives.
• Minimum of 2 years of clinical content development experience or equivalent.
• Preferred experience in Electronic Medical Records (EMR) systems.

Responsibilities

• Leads and supports clinical content development projects from planning through release, including project tracking, scope management, and stakeholder coordination.
• Collaborates with Clinical Leadership, physician researchers, Clinical Managers, and Medical Directors to ensure content accuracy, compliance, consistency, and timely delivery.
• Conducts in-depth medical literature reviews, evaluates and summarizes clinical evidence, and develops comprehensive e-learning materials for physician and nursing audiences.
• Develops specialized appeals arguments related to patient status, DRG validation, and CDI requirements using medical evidence and payer-specific outcomes.
• Applies risk factor logic, decision-making frameworks, and SQL-based validation to ensure content quality across Optum Clinical Groups and InterQual products.
• Analyzes medical claims and denials data, identifies trends, categorizes cases, and recommends content revisions based on data-driven insights.
• Reviews complex medical records, supports AI-assisted clinical research workflows, provides ad hoc analytics and case reviews.

Skills

Clinical content development

Utilization Review

CDI experience

Case management

EMR systems

Excellent communication

Project management

Data analysis

Tools

EMR systems

Job description

ROLE AND RESPONSIBILITIES

• Leads and supports clinical content development projects from planning through release, including project tracking, scope management, and stakeholder coordination.

• Collaborates with Clinical Leadership, physician researchers, Clinical Managers, and Medical Directors to ensure content accuracy, compliance, consistency, and timely delivery.

• Conducts in-depth medical literature reviews, evaluates and summarizes clinical evidence, and develops comprehensive e-learning materials for physician and nursing audiences.

• Develops specialized appeals arguments related to patient status, DRG validation, and Clinical Documentation Improvement (CDI) requirements using medical evidence and payer-specific outcomes.

• Applies risk factor logic, decision-making frameworks, and SQL-based validation to ensure content quality, consistency, and alignment across Optum Clinical Groups and InterQual products.

• Analyzes medical claims and denials data, identifies trends, categorizes cases, develops analytical frameworks, and recommends content revisions based on data-driven insights.

• Reviews complex medical records, supports AI-assisted clinical research workflows, provides ad hoc analytics and case reviews, and confidently defends

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

• Minimum of 10 years of clinical nursing experience as a practicing nurse, demonstrating extensive hands-on patient care expertise in a hospital settings.

• At least 2 years of Utilization Review experience, preferably with Physician Advisor Services or a similar Utilization Review organization.

• Strong knowledge of case management, commercial insurance, Managed Medicare, Traditional Medicare processes, and patient status requirements.

• Experience with Clinical Documentation Improvement (CDI) requirements to support DRG validation and research initiatives.

• Minimum of 2 years of clinical content development experience or equivalent experience in healthcare content creation and review.

• Preferred experience in Electronic Medical Records (EMR) systems.

• Excellent communication, presentation, research, writing, project management, and computer skills, with the ability to apply decision-tree logic in content development and clinical decision-making.
  

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