We are looking for experienced US Registered Nurses (USRNs) to support utilization management activities involving the review of medical necessity, appropriateness, and efficiency of healthcare services through comprehensive evaluation of clinical documentation and medical records while ensuring compliance with payer guidelines and regulatory requirements.
Key Responsibilities
- Conduct prospective, concurrent, and retrospective reviews for inpatient and outpatient cases.
- Assess medical necessity and level of care using established clinical criteria such as InterQual or MCG guidelines.
- Review admissions, continued stays, procedures, and services for appropriateness and compliance with payer requirements.
- Collaborate with physicians, case managers, and healthcare providers to obtain additional clinical information as needed.
- Escalate complex cases to the Medical Director when required for final determination.
- Document review findings and authorization decisions accurately and within required turnaround times.
- Ensure adherence to CMS, NCQA, URAC, HIPAA, and client-specific guidelines.
- Meet established productivity, quality, and service level targets.
- Participate in quality improvement initiatives and team discussions.
Qualifications
- Active and US Registered Nurse (RN) license from any state
- Associate Degree in Nursing (ADN) or Associate of Science in Nursing (ASN) required.
- Must have 1–3 years of hospital or bedside nursing experience in the Emergency Department (ED), Intensive Care Unit (ICU), and/or Medical-Surgical (Med-Surg) setting.
- Experience in Utilization Review (UR), Utilization Management (UM), Case Management, Prior Authorization, or Clinical Appeals is an advantage.
- Experience using InterQual, MCG, or similar utilization management criteria is preferred.
- Strong knowledge of medical necessity guidelines, payer requirements, and healthcare regulations.
- Excellent clinical assessment, analytical, and communication skills.
- Ability to work independently in a fast-paced environment.
Preferred Qualifications
- Experience in managed care, payer, or healthcare BPO environments.
- Familiarity with EMR platforms such as Epic, Cerner, or similar systems.
- Background in acute care, inpatient nursing, or case management is an advantage.
Work Details
- Work Arrangement: Work From Home / Hybrid
- Shift Schedule: Night Shift / US Business Hours
- Employment Type: Full-time
- Location: Open to Philippine-based USRNs
Benefits
- Competitive salary package
- HMO coverage from Day 1
- Night differential and performance incentives
- Paid training and career development opportunities
- Equipment provided for eligible work-from-home employees
