The Role
PHRN Job Description
Position: Philippine Registered Nurse (PHRN)
Industry: Healthcare / BPO
Work Type: Onsite / Hybrid / Remote (depends on account)
Shift: Mostly Night Shift (US Healthcare Account)
Job Summary
The PHRN will support US-based healthcare operations by reviewing clinical cases, processing claims, conducting utilization review, and ensuring medically appropriate and cost-effective care decisions. The role requires strong clinical judgment, excellent communication skills, and accurate documentation.
Key Responsibilities
- Review medical records, clinical notes, and supporting documents to determine medical necessity and appropriateness of care.
- Process claims, pre-authorizations, and appeals based on established clinical guidelines and payer policies.
- Evaluate patient eligibility, benefits coverage, and required approvals.
- Conduct utilization review using tools such as MCG or InterQual (depending on account).
- Coordinate with healthcare providers, physicians, and insurance representatives regarding care plans, denials, and follow-ups.
- Prepare clear, accurate, and professional clinical documentation and rationales.
- Identify discrepancies in claims, coding issues, or billing irregularities.
- Maintain compliance with HIPAA, company policies, and clinical standards.
- Perform case management or care coordination tasks as needed.
- Participate in training, quality audits, and continuous improvement initiatives.
Ideal Profile
- You have at least 2 years experience including solid experience in a similar role within Healthcare and Bedside experience
- You have working knowledge of Pharmacist and Nursin
- You are adaptable and thrive in changing environments
- You are a strong team player who can manage multiple stakeholders
- You pay strong attention to detail and deliver work that is of a high standard
What's on Offer
- Join a well known brand within Hospital / Health Care / Healthtech
- Flexible working options
- A role that offers a breadth of learning opportunities
