Utilization Review Nurse

Omega Healthcare Management Services Pvt. Ltd.; Metro Manila; Remote; PHP 380,000 - 700,000; Full time

Job summary

Omega Healthcare Management Services is seeking a Utilization Review Nurse for a full-time remote role.

You will evaluate medical necessity, appropriateness, and efficiency of healthcare services using clinical criteria and payer guidelines, review medical records, perform concurrent and retrospective reviews, and collaborate with providers, care teams, and payers to ensure high-quality, cost-effective care.

Qualifications

• Strong utilization management skills with pre-authorization, concurrent and retrospective review experience.
• Background in discharge planning and care coordination across multidisciplinary teams.
• Clinical expertise in medicine and nursing with a current, unrestricted RN license in good standing.
• Proficiency in reviewing and interpreting medical records and clinical guidelines.
• Familiarity with payer rules, managed care principles, CMS requirements.

Responsibilities

• Review medical records and documentation to determine medical necessity and appropriateness.
• Perform concurrent and retrospective utilization reviews.
• Collaborate with providers, care teams, and payers to ensure timely, cost-effective, quality care.
• Support discharge planning and care coordination; escalate complex cases as needed.
• Document all activities accurately and maintain regulatory compliance.

Skills

Utilization management

Pre-authorization

Concurrent review

Retrospective review

Discharge planning

Care coordination

Medical record review

CMS & payer rules

Clinical documentation

Remote work

Education

RN license (unrestricted)

Tools

Electronic Health Records (EHR)

Job description

Company Description

Omega Healthcare Management Services is an AI-driven healthcare solutions company that helps organizations across the healthcare ecosystem improve revenue operations and clinical outcomes. Powered by the Omega Digital Platform, the company combines adaptive intelligence and automation with deep human expertise to enhance performance and patient satisfaction. Omega Healthcare supports provider, payer, and life sciences organizations in navigating complex, rapidly changing healthcare and technology environments. Recognized by industry analysts, the company is consistently ranked as a leader in operational performance excellence. For more information, candidates can visit www.omegahms.com.

Role Description

The Utilization Review Nurse is a full-time remote role responsible for evaluating medical necessity, appropriateness, and efficiency of healthcare services using established clinical criteria and payer guidelines. Day-to-day responsibilities include reviewing medical records and documentation, performing concurrent and retrospective utilization reviews, and collaborating with providers, care teams, and payers to ensure timely, cost-effective, and quality care. The role also supports discharge planning and care coordination, identifies opportunities for improved resource utilization, and escalates complex cases as needed. The Utilization Review Nurse will document all review activities accurately, maintain compliance with regulatory and organizational policies, and participate in continuous quality improvement initiatives.

Qualifications

• Strong utilization management skills, including experience with pre-authorization, concurrent review, and retrospective review.
• Background in discharge planning and care coordination, with the ability to collaborate effectively across multidisciplinary teams.
• Clinical expertise in medicine and nursing, with a current, unrestricted RN license (or equivalent clinical license) in good standing.
• Proficiency in reviewing and interpreting medical records, documentation standards, and clinical guidelines.
• Familiarity with payer rules, managed care principles, and regulatory requirements (e.g., CMS, commercial payers).
• Strong analytical, critical thinking, and decision-making skills, with attention to detail and accuracy.
• Excellent written and verbal communication skills, including the ability to explain clinical decisions clearly and professionally.
• Comfort with remote work, including reliable internet access, proficiency with electronic health records and other digital tools, and strong time management skills.
• Preferred: Experience in utilization review, case management, or care management; certification such as CCM, CPUR, or CPUM is a plus.