Utilization Review Nurse — Denials & Appeals

PM Consulting; Metro Manila; On-site; PHP 670,000 - 1,116,000; Full time

Job summary

PM Consulting is seeking a US Registered Nurse (USRN) to support clinical review and healthcare operations from the Philippines. The role focuses on evaluating medical records, validating clinical necessity, and ensuring compliance with payer and regulatory standards to drive accurate reimbursement outcomes.

You will conduct utilization review, review patient records, perform prior authorizations, and collaborate with providers and cross-functional teams.

Qualifications

• Active US RN license (unrestricted).
• BSN preferred.
• 3 years bedside ICU/ER/Med-Surg experience.
• Strong knowledge of payer policies and CMS regulations.
• Excellent clinical judgment, analytical thinking, and documentation skills.
• Ability to work in a fast-paced, performance-driven environment.

Responsibilities

• Conduct utilization review and evaluate medical necessity using established clinical criteria and guidelines.
• Review patient medical records to assess level of care, treatment plans, and medical services rendered.
• Ensure adherence to payer policies, CMS regulations, and healthcare industry standards.
• Perform prior authorization, concurrent review, and other utilization management activities as required.
• Support denial management by reviewing clinical cases and providing appeal-related clinical recommendations.
• Collaborate with providers, clinicians, and cross-functional teams to resolve documentation gaps.
• Maintain productivity, quality, and performance metrics based on operational targets.
• Document review findings accurately in designated clinical systems and platforms.
• Stay updated on current US healthcare regulations, payer requirements, and clinical practice standards.

Skills

USRN license

Clinical documentation

Utilization review

Regulatory compliance

Education

BSN preferred

Job description

PM Consulting is seeking a US Registered Nurse (USRN) to support clinical review and healthcare operations from the Philippines. The role focuses on evaluating medical records, validating clinical necessity, and ensuring compliance with payer and regulatory standards to drive accurate reimbursement outcomes.

You will conduct utilization review, review patient records, perform prior authorizations, and collaborate with providers and cross-functional teams.