Utilization Review Nurse - WFH

Med-Metrix; Pasig; On-site; PHP 446,400 - 669,600; Full time

Benefits offered by this job

8-Hour Shifts

Day 1 HMO coverage for dependents

Group Life Insurance

Medical Cash Allowance

Clothing Allowance

Paid Time Off

Free Lunch Daily

Training and Staff Development

Job summary

A healthcare management company is seeking a Utilization Review Nurse to evaluate the medical necessity of healthcare services. The role requires a valid PHRN license with experience in utilization management and clinical nursing. Responsibilities include conducting reviews and collaborating with healthcare providers to optimize member outcomes. This full-time position offers hybrid work arrangements and requires effective communication skills in English.

Qualifications

• Valid PHRN license; USRN license is a plus.
• 1-2 years experience in Utilization Management.
• Experience with UM criteria like MCG or InterQual.
• 2+ years clinical nursing experience in ambulatory or hospital setting.
• Proficient with Microsoft web-based applications.
• Experience in managed care and health insurance required.
• Effective communication in English, both written and verbal.

Responsibilities

• Conduct pre-certification and inpatient reviews as per UM policies.
• Determine medical necessity using initial clinical information.
• Collaborate with healthcare providers for optimal member outcomes.
• Review benefit determinations.
• Consult with UM Medical Director on medical necessity.
• Perform continued stay reviews and discharge planning.
• Generate written correspondence adhering to UM policies.

Skills

Clinical Nursing Experience

Utilization Management Criteria

Communication Skills

Computer Skills

Education

PHRN License

USRN License

Job description

Utilization Review Nurse

Company: Med-Metrix

Location: Pasig, National Capital Region, Philippines

Benefits

• 8-Hour Shifts
• Day 1 HMO with 2 of your dependents covered for FREE
• Group Life Insurance
• Medical Cash Allowance
• Rice Allowance
• Clothing Allowance
• Holiday Gift
• Bereavement Assistance
• Free Lunch Daily
• Paid Time Off
• Training and Staff Development
• Employee Engagement Activities
• Opportunities for Internal Mobility

Job Purpose

The Utilization Management Review Nurse reviews the medical necessity and appropriateness of healthcare services and treatments through the medical information of individual patients and the limited insurance coverage available to them. The Utilization Management Review Nurse works with healthcare providers, insurance companies, and patients to ensure the quality of patient care is cost efficient.

Duties and Responsibilities

• Conducts pre-certification, inpatient, retrospective reviews, in accordance with UM policies and procedures.
• Conducts initial medical necessity reviews. Determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review.
• Collaborate with healthcare providers to promote the most appropriate, highest quality member outcomes, and to optimize member benefits.
• Conducts initial benefit determination reviews.
• Consults with UM Medical Director to review requests that do not meet medical necessity.
• Performs continued stay review, care coordination, and discharge planning for appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.
• Generates appropriate written correspondence to providers and/or members in accordance with UM policies and procedures.
• Adheres to company policies and procedures regarding confidentiality and privacy.

Qualifications

• Must have valid PHRN License; USRN license is a plus.
• Minimum of 1 - 2 years experience in Utilization Management.
• Experience utilizing UM criteria including MCG or InterQual.
• Minimum of three (2) years clinical nursing experience in an ambulatory or hospital setting.
• Proficient computer skills and experience with Microsoft web-based applications.
• Experience in managed care and health insurance required.
• Ability to communicate effectively English, both written and verbal.
• Ability to work holiday and weekend rotation.

Working Conditions

• Work Set-Up: Hybrid
• Work Schedule: Night shift, US hours; PH holidays and weekend rotation.
• Physical Demands: While performing the duties of this job, the employee is occasionally required to move around the work area; Sit; perform manual tasks; operate tools and other office equipment such as computer, computer peripherals and telephones; extend arms; kneel; talk and hear.
• Mental Demands: The employee must be able to follow directions, collaborate with others, and handle stress.
• Work Environment: The noise level in the work environment is usually minimal.

Seniority Level

Mid-Senior level

Employment Type

Full-time

Job Function

Health Care Provider