The US Registered Nurse (USRN) will support clinical review and healthcare operations by evaluating medical records, validating clinical necessity, and ensuring compliance with payer and regulatory standards. This role focuses on supporting accurate reimbursement outcomes through clinical documentation review, utilization management, and collaborative case assessment.

Key Responsibilities

• Conduct utilization review and evaluate medical necessity using established clinical criteria and guidelines.

• Review patient medical records to assess level of care, treatment plans, and medical services rendered.

• Ensure adherence to payer policies, CMS regulations, and healthcare industry standards.

• Perform prior authorization, concurrent review, and other utilization management activities as required.

• Support denial management by reviewing clinical cases and providing appeal-related clinical recommendations.

• Collaborate with providers, clinicians, and cross-functional teams to resolve documentation gaps.

• Maintain productivity, quality, and performance metrics based on operational targets.

• Document review findings accurately in designated clinical systems and platforms.

• Stay updated on current US healthcare regulations, payer requirements, and clinical practice standards.

Qualifications

• Active and unrestricted US Registered Nurse (RN) license (required).

• Bachelor of Science in Nursing (BSN) preferred.

• 1–3 years of bedside experience in ICU, ER, Medical-Surgical setting.

• 1 year of utilization review, case management, prior authorization, or clinical appeals experience

• Strong knowledge of the US healthcare system, clinical standards, and payer guidelines.

• Excellent clinical judgment, analytical thinking, and documentation skills.

• Ability to work in a fast-paced, performance-driven environment.

Preferred Experience

• Experience supporting US payer or provider healthcare accounts.

• Familiarity with clinical decision support tools such as InterQual, MCG, or similar platforms.

• Background in denial management or clinical documentation review.

• Experience in healthcare BPO, shared services, or outsourcing environments.