Utilization Review Nurse: Drive Clinical Compliance & Outcomes

Cognizant Technology Solutions Philippines Inc.; Taguig; On-site; PHP 500,000 - 700,000; Full time

Job summary

Cognizant Technology Solutions Philippines Inc. is seeking USRN Utilization Management Nurses to deliver high-quality healthcare support and drive positive patient outcomes.

You will conduct UM reviews, evaluate medical necessity, and coordinate with physicians to ensure timely determinations while upholding HIPAA requirements. Ideal candidates hold a BS Nursing degree with active PHRN/USRN licenses and UM experience.

Qualifications

• BS Nursing graduate.
• Active PHRN and USRN license.
• US Mainland license holder preferred.
• With Utilization Management experience.
• Excellent verbal and written communication skills.
• Comfortable handling voice-based healthcare processes.
• Willing to work onsite in Taguig.

Responsibilities

• Conduct utilization management (UM) reviews for inpatient and outpatient services, medications, and treatment requests based on clinical guidelines and client requirements.
• Evaluate medical necessity and refer cases requiring further review to physician reviewers.
• Ensure compliance with regulatory standards, URAC guidelines, client policies, and established turnaround times.
• Coordinate with physicians, healthcare providers, and stakeholders to facilitate timely review outcomes and determinations.
• Maintain accurate documentation and case records within utilization management systems.
• Communicate UM determinations and respond to member, provider, and stakeholder inquiries in a professional and timely manner.
• Support quality, compliance, and customer service objectives while safeguarding patient information and HIPAA requirements.
• Collaborate with healthcare and operations teams to improve processes, ensure service excellence, and drive positive patient outcomes.

Skills

Verbal & written communication

Utilization Management experience

Voice-based healthcare processes

Education

BS Nursing

PHRN and USRN license

US Mainland license preferred

Job description

Cognizant Technology Solutions Philippines Inc. is seeking USRN Utilization Management Nurses to deliver high-quality healthcare support and drive positive patient outcomes.

You will conduct UM reviews, evaluate medical necessity, and coordinate with physicians to ensure timely determinations while upholding HIPAA requirements. Ideal candidates hold a BS Nursing degree with active PHRN/USRN licenses and UM experience.