Job Title: Clinical Utilization Management Nurse Specialist (USRN)

Program: Healthcare – Hybrid Voice and Back-Office Operations

Work Location: Vertis North, Quezon City

Work Setup: Onsite

Shift Schedule: US Day Shift

Target Stwart Date: On or before December 15

Headcount: 6

Job Overview

Use your clinical expertise to review prior authorization and concurrent review requests against established clinical guidelines. Ensure members receive appropriate, timely, and cost-effective care within a US managed care environment.

Key Responsibilities

Review prior authorization and/or concurrent review requests to determine medical necessity and the appropriate level of care.

Coordinate with healthcare providers and internal teams to ensure timely case resolution.

Escalate cases requiring a higher level of clinical review to Medical Directors.

Support discharge planning and transfer authorization workflows for concurrent review cases.

Accurately document clinical findings and case decisions in accordance with established standards.

Guide healthcare providers and internal teams on utilization management processes.

Qualifications

Graduate of an accredited nursing school with a Bachelor of Science in Nursing (BSN).

Active, unrestricted USRN license with NCLEX passed.

At least 1 year of clinical experience in a hospital, clinic, or academic setting, plus 1year of Utilization Management experience; or at least 2 years of experience in Utilization Management, Prior Authorization, or Concurrent Review.

Strong understanding of Medicare, Medicaid, and US managed care fundamentals.

Excellent analytical, clinical documentation, and communication skills.

Willing to work onsite in Vertis North, Quezon City, on a US day shift.

Healthcare BPO or healthcare payer experience.

Background in Utilization Review (UR) and Utilization Management (UM), particularly Prior Authorization or Concurrent Review.

Familiarity with InterQual, MCG, or similar clinical decision-support criteria tools.