Discover your 100% YOU with MicroSourcing!Position: Utilization Review Nurse Specialist
Location: Taguig
Work setup & shift: Onsite | Night shift
Sign-on bonus: 50,000.Why join MicroSourcing Youu0027ll have:
- 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.
Our client,
Huron, is a global professional services firm that collaborates with clients to put possibilities into practice by creating sound strategies, optimizing operations, accelerating digital transformation, and empowering businesses and their people to own their future. By embracing diverse perspectives, encouraging new ideas, and challenging the status quo, Huron creates sustainable results for the organizations they serve.
Your Role The
Utilization Review Nurse Specialist is responsible for optimizing clinical outcomes and controlling patient care costs by confirming that healthcare services provided are medically necessary, appropriate, and efficient. The Utilization Review Nurse Specialist collaborates extensively with physicians, case managers, and payers to facilitate timely authorizations, manage concurrent denials, and contribute to quality improvement initiatives. This role is fundamental in fostering innovation, improving patient outcomes, and promoting financially sustainable healthcare operations.
As a
Utilization Review Nurse Specialist, you will:
Utilization Review- Conduct thorough initial, concurrent, and retrospective reviews of patient medical records to determine the medical necessity and appropriate level of care, utilizing InterQual, MCG, or similar guidelines.
- Collaborate with physicians and other healthcare professionals to ensure accurate documentation is provided to payors, supporting the progression of care.
- Ensure strict compliance with payer requirements and regulatory standards, including Medicare, Medicaid, NCQA, and HIPAA.
- Prepare and submit supplemental clinical documentation for reconsideration of concurrent denials, substantiating medical necessity.
- Monitor work queues for payor requests, clinical denials, and pending reviews.
- Monitor portals, voice mails, and emails for authorizations, and record information as required.
- Track utilization data and identify trends to support quality improvement initiatives.
Quality and Compliance- Participate in building quality assurance (QA) programs, including workflow audits and implementing automation or efficiency tools.
- Monitor performance metrics for utilization management and concurrent clinical denials, focusing on productivity and accuracy.
- Escalate production and QA concerns to management when necessary.
- Demonstrate expertise in quality processes related to documentation of medical diagnoses and treatment practices.
Collaboration and Support- Work closely with physicians, case managers, social workers, and payers to ensure precise medical necessity documentation, supporting care provision and progression.
- Serve as the primary liaison between the hospital and insurance carriers for continued stay authorizations.
- Participate in client calibration calls to align training KPIs with operational metrics.
- Support internal audits and process reviews by presenting dashboards and highlighting achievements.
Development- Complete ongoing training and development in leading practices.
- Maintain and monitor individual KPI performance.
Other duties and responsibilities as assigned. What You NeedNon-negotiables- Utilization Review Experience: At least 1 year of utilization review experience.
- Clinical Experience: Minimum of 3-5 years acute care clinical experience in a hospital setting (Med/Surg, or similar preferred
