Utilization Review Nurse - IP & OP

MicroSourcing; Taguig; On-site; PHP 669,600 - 1,004,400; Full time

Benefits offered by this job

Sign-on bonus

Healthcare from day one

Paid time off with cash conversion

Group life insurance

Performance bonuses

Team events

Flexible work arrangements

Job summary

MicroSourcing is seeking a skilled Utilization Review Nurse - IP & OP for onsite night shift at BGC, Taguig City. You will review denied claims, manage appeals, and ensure timely submission to payors.

Ideal candidates have 1 year of clinical appeals experience, 3–5 years acute care nursing, a BSN, and an active US RN or PH registered license. Proficiency with InterQual/MCG and major EMR systems is preferred.

Qualifications

• 1 year of clinical appeal writing experience.
• 3–5 years acute care clinical experience in a hospital setting; ICU 2–3 years.
• Bachelor of Science in Nursing.
• Active PHRN or USRN license.
• Proficiency with InterQual/MCG guidelines.
• Experience with EMR systems (Epic/Cerner/Meditech).
• Fluent English communication (CEFR B2).

Responsibilities

• Review denied claims and manage appeals timely.
• Respond to denial reasons and resubmit information to payors.
• Coordinate with engagement teams and document all actions.
• Submit retro-authorizations as required by payors.
• Prepare clinical documentation summaries for appeals.
• Track denials and appeals progress and outcomes.
• Stay updated on payer policies and industry best practices.

Skills

Clinical appeals

Acute care

RN license

InterQual/MCG

EMR systems

English communication

Education

Bachelor of Science in Nursing

Tools

Epic EMR

Cerner EMR

Meditech EMR

Job description

Discover your 100% YOU with MicroSourcing!

Position

Utilization Review Nurse - IP & OP

Location

BGC, Taguig City

Work setup & shift

Onsite | Night shift

Sign-on bonus

50,000*

Why join MicroSourcing?

• Competitive Rewards: Enjoy above-market compensation, healthcare coverage on day one, plus one or more dependents, paid time‑off with cash conversion, group life insurance, and performance bonuses
• A Collaborative Spirit: Contribute to a positive and engaging work environment by participating in company‑sponsored events and activities.
• Work‑Life Harmony: Enjoy the balance between work and life that suits you with flexible work arrangements.
• Career Growth: Take advantage of opportunities for continuous learning and career advancement.
• Inclusive Teamwork: Be part of a team that celebrates diversity and fosters an inclusive culture.

Your Role

The Utilization Review Nurse - IP & OP is responsible for reviewing the claims denied and carrying out the appeals process appropriately and in a timely manner. This individual identifies and works on denials, responding to the denial reason and resubmitting any information needed to the payor. The Clinical Denials and Appeals Specialist should be knowledgeable of U.S. state/federal laws that relate to payor contracts and to the appeals process. This role requires frequent and effective communication via phone, email, and instant messaging with the various engagement teams. Strong oral and written communication skills, analytical skills, ability to work independently, and self‑motivation are required.

As a Clinical Denials & Appeals Nurse Specialist – IP & OP, you will:

• Work denials and appeals timely, evaluating the denial reason, including information from the payor and payor policies, reviewing the clinical documentation, assessing options, and completing next steps
• Submit retro‑authorizations in accordance with payor requirements in response to authorization denials
• Conduct medical necessity reviews, based on the denial root cause, and prepare any required clinical documentation summaries to accompany appeals.
• Write and submit written appeals that include compelling arguments based on clinical documentation, third‑party payer medical policies, and contract language. Appeals are submitted timely and tracked through the final outcome.
• Document all actions taken and follow up timely as needed related to resolving denials and appeals with third‑party payers in a timely manner
• Track the status and progress of denials and appeals
• Completes relevant research to assist with completing the appeals process and to stay informed on best practices and policy reforms
• Executes internal and external correspondence accurately, clearly, concisely, and professionally while following organizational regulations
• Effectively handles all communications, including telephone, electronic, and paper correspondence from payers and departments within the business office

Tracking, Reporting, and Trends

• Maintain data on the types of claims denied and the root causes of denials
• Identify denial patterns and elevate to management as appropriate with sufficient information for additional follow‑up, and/or root‑cause resolution
• Collaborate with management to recommend process changes to address the root cause of denials and overall improvement to reduce A/R
• Prepares, maintains, assists with, and submits reports as required

Compliance and Continuous Improvement

• Collaborate with team members to continually improve services, and engage in process and quality improvement activities
• Identify system improvement opportunities and contribute to the testing of system modifications
• Conduct relevant research to assist with completing the appeals process and stay informed on best practices and policy reforms
• Complies with state and federal regulations, accreditation/compliance requirements, and Huron’s policies, including those regarding fraud and abuse, confidentiality, and HIPAA
• Maintains a thorough understanding of federal and state regulations, as well as specific payer requirements and explanations of benefits, in order to identify and report billing compliance issues and payer discrepancies
• Participates in ongoing professional development to enhance job knowledge and performance
• Reports all identified compliance risks to appropriate leadership

What You Need

Non‑negotiables

• Clinical Appeals Experience: At least 1 year of clinical appeal writing experience.
• Clinical Experience: Minimum of 3-5 years acute care clinical experience in a hospital setting (Med/Surg, or similar preferred); 2-3 years of ICU experience.
• Education: Bachelor of Science in Nursing.
• Licensure: Must be a Registered Nurse with an active PHRN or USRN license.
• RCM Knowledge: Proficiency in using InterQual or MCG clinical guidelines. Broad Knowledge of U.S. Government Programs and Insurance Regulations
• Software Knowledge: Proficiency with hospital‑based electronic medical records (EMR) such as Epic, Cerner, or Meditech.
• Excellent verbal and written English communication skills and customer service skills (CEFR level of at least B2 for both verbal and written)

Preferred Skills / Expertise

• Education: Master’s degree or credential in business, healthcare, or related field preferred
• Credential/Certification: Case management, clinical appeals, or clinical denials certification (ACMA) is preferred.
• Software Knowledge: Proficiency in using computer programs for tracking denials and appeals. Proficiency with Microsoft Office suite (Excel, Word, PowerPoint, Outlook, SharePoint)

Soft Skills

• Ability to pay close attention to details; strong follow‑up and follow‑through skills
• Regularly makes complex decisions within the scope of the position, and is comfortable working independently
• Requires the use of independent judgment, discretion and decision‑making abilities
• Demonstrates teamwork and integrity in all work‑related activities
• Ability to interact with internal and external customers in a professional manner
• Strong analytical and critical thinking skills.
• Experience in a matrixed environment
• Excellent written and verbal communication skills

Terms & conditions apply