Registered Nurse PHRN Utilization Review

About This Role

This role involves joining a team as a Utilization Review Nurse, focusing on reviewing medical records and clinical documentation. It suits Philippine Registered Nurses with strong clinical knowledge and attention to detail, who have experience with healthcare documentation.

Responsibilities

• Review medical records, clinical documentation, and patient information to determine medical necessity and appropriateness of services
• Conduct utilization reviews based on established clinical guidelines and payer requirements
• Assess inpatient and outpatient cases for level of care, length of stay, and appropriate utilization of healthcare services
• Collaborate with physicians, case managers, hospitals, and other healthcare professionals as needed
• Identify potential gaps in documentation and request additional clinical information when necessary
• Ensure accurate and timely documentation of utilization review decisions
• Maintain compliance with company policies, healthcare regulations, and client requirements
• Meet established productivity, quality, and turnaround-time standards
• Protect patient confidentiality and comply with applicable privacy regulations

Requirements

• Active Philippine Registered Nurse (PHRN) license
• Acute hospital bedside experience: 1 year (Required)
• Utilization Review Nurse experience: 1 year (Required)
• Strong understanding of medical terminology, clinical documentation, and healthcare processes
• Excellent written and verbal communication skills
• Strong analytical, organizational, and decision-making skills
• Detail-oriented and able to work independently
• Willing to work on night shifts, weekends, holidays, and/or shifting schedules as required
• Willing to report in Alabang during training period

Nice to have:

• Experience in a healthcare BPO (Insurance, Denials & Appeals, Utilization Review, Prior Authorization, Medical Coding, etc.)

Benefits

• Additional leave
• Company events
• Health insurance
• Life insurance
• Opportunities for promotion
• Paid training
• Pay raise
• Promotion to permanent employee
• Staff meals provided
• Transportation service provided