Utilization Review Nurse

Discover your 100% YOU with MicroSourcing!

Position: Utilization Review Nurse Specialist

Location: BGC, Taguig City

Work setup & shift: Onsite | Night shift

Sign-on bonus: 50,000*

Why join MicroSourcing?

Youll 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.

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 Need

Non-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); 2-3 years of ICU experience.
• Education: Bachelor of Science in Nursing.
• Licensure: Must be a Registered Nurse with an active PHRN or USRN license.
• RCM Knowledge: Proficiency in using InterQual or MCG clinical guidelines. Broad Knowledge of U.S. Government Programs and Insurance Regulations
• Software Knowledge: Proficiency with hospital-based electronic medical records (EMR) such as Epic, Cerner, or Meditech.
• Excellent verbal and written English communication skills and customer service skills (CEFR level of at least B2 for both verbal and written)

Preferred skills/expertise

• Education: Master’s degree or credential in business, healthcare, or related field preferred
• Credential/Certification: Case management, clinical appeals, or clinical denials certification is preferred.
• Software Knowledge: Proficiency in using computer programs for tracking authorizations, denials, and appeals. Proficiency with Microsoft Office suite (Excel, Word, PowerPoint, Outlook, SharePoint)
• Soft Skills: Ability to pay close attention to details; strong follow-up and follow-through skills
• Regularly makes complex decisions within the scope of the position, and is comfortable working independently
• Requires the use of independent judgment, discretion, and decision-making abilities
• Demonstrates teamwork and integrity in all work-related activities
• Ability to interact with internal and external customers in a professional manner
• Strong analytical and critical thinking skills.
• Experience in a matrixed environment
• Excellent written and verbal communication skills

About MicroSourcing

With over 9,000 professionals across 13 delivery centers, MicroSourcing is the pioneer and largest offshore provider of managed services in the Philippines.

Our commitment to 100% YOU

MicroSourcing firmly believes that our companys strength lies in our peoples diversity and talent. We are proud to foster an inclusive culture that embraces individuals of all races, genders, ethnicities, abilities, and backgrounds. We provide space for everyone, embracing different perspectives, and making room for opportunities for each individual to thrive.

At MicroSourcing, equality is not merely a slogan - its our commitment and our way of life. Here, we dont just accept your unique, authentic self—we celebrate it, valuing every individuals contribution to our collective success and growth. Join us in celebrating YOU and your 100%!

For more information, visit www.microsourcing.com

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