Utilization Management Review [Registered Pharmacist Required]

Swift-up; Taguig; On-site; PHP 600,000 - 900,000; Full time

Job summary

Swift-up is seeking an Utilization Management Reviewer to evaluate medical necessity and appropriateness across inpatient and outpatient settings, using INTERQUAL or MCG guidelines to support decisions.

You will review documentation, collaborate with physicians and care teams, and communicate outcomes to providers and payers. The role also includes audits, guidance on criteria, and ongoing education on utilization management practices.

Qualifications

• Proficient in INTERQUAL or MCG guidelines for utilization management decisions.

Responsibilities

• Conduct concurrent, retrospective, and pre-authorization reviews using MCG criteria to assess the medical necessity and level of care
• Analyze clinical documentation and apply evidence-based standards to support utilization determinations
• Collaborate with physicians, case managers, and other members of the care team to ensure appropriate care transitions and timely discharges
• Communicate review outcomes to providers and payers, including approvals, denials, or requests for additional information
• Document all reviews, determinations, and communications in accordance with internal and regulatory requirements
• Provide guidance to clinical teams on MCG criteria and payer authorization processes
• Participate in audits, quality improvement initiatives, and staff education related to utilization management
• Stay up-to-date with regulatory changes, payer policies, and updates to MCG guidelines

Skills

INTERQUAL/MCG

Job description

About the role

The Utilization Management Reviewer is responsible for evaluating the medical necessity, appropriateness, and efficiency of healthcare services across inpatient and outpatient settings. This role ensures that care aligns with clinical guidelines, payer requirements, and organizational policies — with a strong emphasis on proficiency in INTERQUAL OR MCG (Milliman Care Guidelines) for utilization management decisions.

Key responsibilities

• Conduct concurrent, retrospective, and pre-authorization reviews using MCG criteria to assess the medical necessity and level of care
• Analyze clinical documentation and apply evidence-based standards to support utilization determinations
• Collaborate with physicians, case managers, and other members of the care team to ensure appropriate care transitions and timely discharges
• Communicate review outcomes to providers and payers, including approvals, denials, or requests for additional information
• Document all reviews, determinations, and communications in accordance with internal and regulatory requirements
• Provide guidance to clinical teams on MCG criteria and payer authorization processes
• Participate in audits, quality improvement initiatives, and staff education related to utilization management
• Stay up-to-date with regulatory changes, payer policies, and updates to MCG guidelines

About you

• Proficiency in INTERQUAL OR MCG (Milliman Care Guidelines) for utilization management decisions