Utilization Review Nurse

MicroSourcing; Philippines; On-site; PHP 600,000 - 900,000; Full time

Job summary

MicroSourcing in the Philippines is seeking a Utilization & Denials Management Supervisor to lead a team of Utilization Review and Clinical Denials & Appeals specialists. You will oversee staffing, coaching, and performance to ensure adherence to payer guidelines and SLAs.

Responsibilities include monitoring productivity and quality, auditing compliance, analyzing denial trends, and partnering with cross-functional teams to drive process improvements in utilization management and revenue cycle

Qualifications

• Bachelor of Science in Nursing with active licensure (PHRN or USRN).
• At least 1 year of supervisory experience in Utilization Management or Clinical Denials & Appeals.
• 3–5 years of acute care clinical experience (Med/Surg; ICU if applicable).
• Proficiency with InterQual or MCG guidelines; strong knowledge of US healthcare regulations and revenue cycle processes.
• Experience with hospital EMR systems (Epic, Cerner, Meditech).
• Good command of English (CEFR B2) and strong communication skills.
• Proven leadership, coaching, and ability to manage multiple priorities.

Responsibilities

• Lead and supervise a team of Utilization Review and Denials & Appeals specialists.
• Monitor productivity, quality, turnaround time, and SLAs; address performance gaps.
• Oversee review and resolution of utilization management and denials; handle escalations.
• Conduct audits to ensure payer compliance and documentation standards.
• Analyze denial trends and collaborate across Billing, Coding, HIM, and Revenue Integrity.
• Develop and present KPI dashboards and reports to leadership.
• Collaborate with IT and cross-functional teams to optimize EMR and denials systems.
• Mentor staff on utilization management and regulatory updates.

Skills

Nursing degree

PHRN/USRN license

Supervisory experience

InterQual/MCG guidelines

EMR (Epic/Cerner/Meditech)

CEFR B2 English

Leadership

Education

Bachelor of Science in Nursing

Tools

Epic

Cerner

Meditech

MS Office Suite

Job description

Discover your 100% YOU with MicroSourcing!

Work setup & shift: Onsite | Night Shift

Your Role:

As a Utilization & Denials Management Supervisor, you will:

• Lead and supervise a team of Utilization Review and Clinical Denials & Appeals specialists, overseeing hiring, onboarding, scheduling, coaching, and performance management.
• Monitor team productivity, quality, accuracy, turnaround time, and service level agreements (SLAs), implementing action plans to address performance gaps and prevent operational backlogs.
• Oversee the timely review and resolution of utilization management, clinical denials, and appeals, including escalated at-risk accounts in accordance with client and payer guidelines.
• Conduct audits and quality reviews to ensure compliance with payer regulations, utilization management standards, and clinical documentation requirements.
• Analyze denial trends and partner with Billing, Revenue Cycle, Coding, HIM, Revenue Integrity, and Clinical teams to identify root causes and implement process improvements.
• Develop and present operational reports, KPI scorecards, dashboards, and performance updates to leadership while driving continuous improvement initiatives.
• Collaborate with IT and cross-functional stakeholders to optimize EMR, encoder, utilization management, and denials management systems.
• Mentor and educate team members on utilization management, clinical denials, documentation requirements, regulatory updates, and best practices to support professional growth and operational excellence.

What You Need:

• Bachelor of Science in Nursing with an active PHRN or USRN license.
• At least 1 year of supervisory experience in Utilization Management and/or Clinical Denials & Appeals.
• 3-5 years of acute care clinical experience in a hospital setting (Med/Surg or similar preferred; 2-3 years if ICU experience).
• Proficiency using InterQual or MCG clinical guidelines, with a strong understanding of U.S. healthcare regulations, utilization management, and revenue cycle processes.
• Experience using hospital-based Electronic Medical Records (EMR) such as Epic, Cerner, or Meditech.
• Excellent verbal and written English communication skills (minimum CEFR B2 proficiency).
• Strong leadership, coaching, analytical, and decision-making skills with the ability to manage multiple priorities in a fast-paced healthcare environment.

Preferred skills/expertise

• Master's degree in Business, Healthcare, or a related field.
• ACMA or other Case Management, Clinical Appeals, or Clinical Denials certification.
• Proficiency with authorization, utilization management, denials tracking systems, and the Microsoft Office Suite (Excel, Word, PowerPoint, Outlook, SharePoint).
• Experience creating KPI dashboards, operational scorecards, and client-facing reports.
• Proven ability to lead cross-functional projects, influence stakeholders, and drive continuous process improvement within healthcare revenue cycle operations.

About MicroSourcing

With over 9,000 professionals across 13 delivery centers, MicroSourcing is the pioneer and largest offshore provider of managed services in the Philippines.

Our Commitment to 100% YOU

MicroSourcing firmly believes that our company's strength lies in our people's diversity and talent. We are proud to foster an inclusive culture that embraces individuals of all races, genders, ethnicities, abilities, and backgrounds. We provide space for everyone, embracing different perspectives, and making room for opportunities for each individual to thrive.

At MicroSourcing, equality is not merely a slogan- it's our commitment. Our way of life. Here, we don't just accept your unique authentic self- we celebrate it, valuing every individual's

contribution to our collective success and growth.

Join us in celebrating YOU and your 100%!