Utilization Review Nurse

Omega Healthcare Management Services is seeking a highly motivated and detail-oriented Utilization Review Nurse (PHRN) to join our healthcare operations team. The successful candidate will be responsible for reviewing clinical documentation, evaluating medical necessity, and ensuring compliance with payer guidelines and utilization management standards.

This role is ideal for Registered Nurses who have strong clinical assessment skills and are looking to transition into a healthcare BPO and utilization management environment.

Key Responsibilities
•Review medical records, treatment plans, and authorization requests to determine medical necessity and appropriateness of care.

•Analyze clinical documentation to ensure compliance with payer policies and utilization management guidelines.

•Assist in handling denials, appeals, and reimbursement-related concerns.

Qualifications
•Active Philippine Registered Nurse (PHRN) license.

•Previous Utilization Review, Clinical Appeals and denials experience.

•Excellent analytical, critical thinking, and decision-making skills.

•Strong verbal and written communication skills.