Utilization Review Nurse – Clinical Determinations

Optum, a UnitedHealth Group Company; Metro Manila; On-site; PHP 300,000 - 600,000; Full time

Benefits offered by this job

Market Total Rewards Package

Retirement Plan

Medical Plan (HMO) from Day 1 of emloy

Dental, Medical, and Optical Reimburse

Life and Disability Insurance

Paid Time-Off Benefits

Sick Leave Conversion

Tuition Fee Reimbursement

Employee Assistance Program (EAP)

Annual Performance Based Merit Increa

Employee Recognition

Training and Staff Development

Employee Referral Program

Employee Volunteerism Opportunity

All Mandatory Statutory Benefits

Job summary

Optum, a UnitedHealth Group company, seeks a qualified nurse reviewer to support pre-service clinical coverage determinations. You will assess medical necessity and interpret medical records to inform care decisions.

The role emphasizes regulatory compliance, HIPAA guidelines, and collaboration with health plans and providers to ensure high-quality patient care. Experience in hospital settings and strong data navigation are essential.

Qualifications

• Valid and unrestricted USRN and PHRN Licenses required.
• Minimum of 2 years hospital bedside experience (ICU, ER, Med-Surg, CCU).
• Clinical competence in hospital care and care coordination.
• Knowledge in computer navigation.

Responsibilities

• Function is responsible for performing pre-service clinical coverage review of services that require notification, using applicable benefit plan documents, evidence-based medical policy and nationally recognized clinical guidelines and criteria.
• Determines medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination.
• Review Existing Clinical Documentation: Review/interpret clinical/medical records submitted from provider (e.g., office records, test results, prior operative reports).
• Make Final Determinations Based on Clinical and Departmental Guidelines, adhering to legal/regulatory requirements (HIPAA, CMS, NCQA/URAC).
• Achieve and Maintain Established Productivity and Quality Goals, following quality audit standards in reviews and documentation.

Skills

USRN license

PHRN license

Hospital bedside experience

Clinical care coordination

Computer navigation

Job description

Optum, a UnitedHealth Group company, seeks a qualified nurse reviewer to support pre-service clinical coverage determinations. You will assess medical necessity and interpret medical records to inform care decisions.

The role emphasizes regulatory compliance, HIPAA guidelines, and collaboration with health plans and providers to ensure high-quality patient care. Experience in hospital settings and strong data navigation are essential.