Utilization Review Nurse | UMR | PHRN | Pasay

Access Healthcare Services Manila, Inc.; Pasay; On-site; PHP 223,200 - 334,800; Full time

Job summary

A healthcare service provider in Pasay is seeking a highly skilled PH Registered Nurse (PHRN) to join their team. The ideal candidate must have an active PHRN license and at least 1 year of clinical experience. Responsibilities include conducting clinical reviews, analyzing patient records for medical necessity, and collaborating with medical directors. This is a full-time on-site position offering opportunities for quality improvement in patient care.

Qualifications

• Active PHRN license required.
• At least 1 year of clinical nursing experience in utilization review or case management preferred.
• Must have minimum acute bedside experience.

Responsibilities

• Conduct clinical reviews of inpatient and outpatient services.
• Analyze patient records for medical necessity.
• Collaborate with medical directors on complex cases.
• Ensure compliance with regulatory guidelines.
• Document and maintain review records.

Skills

Clinical nursing experience

Utilization review

Case management

InterQual guidelines

MCG guidelines

Education

Bachelor's degree in Nursing

Tools

InterQual

MCG

NCD

LCD

Job description

Access Healthcare Services Manila, Inc.

On-site - Pasay 1-3 Yrs Exp Bachelor Full-time

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Job Description

We are seeking a highly skilled and detail-orientedPH Registered Nurse (PHRN)to join our team.

The ideal candidate will have hands-on experience withInterQual,MCG,NCD, andLCDGuidelines

Key Responsibilities

• Conduct clinical reviews of inpatient and outpatient services using InterQual, MCG, NCD, and LCD criteria.
• Analyze patient records to determine the medical necessity and appropriateness of services.
• Collaborate with medical directors and multidisciplinary teams to review complex cases.
• Ensure compliance with regulatory and payer-specific guidelines.
• Document and maintain accurate and comprehensive review records.
• Participate in quality improvement and audit initiatives.

Qualifications

• Active PHRN license
• at least 1 year of clinical nursing experience in utilization review or case management experience preferred.
• Must have minimum acute bedside experience
• Proficient in usingInterQualandMCG guidelines.
• Strong working knowledge ofNCD and LCDcriteria and application.
• Experience in developing or implementingclinical decision treesor algorithms.

Working Location

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• collects illicit benefits,
• or other illegal situations.

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