We are looking for a USRN Utilization Review Specialist responsible for reviewing clinical information, medical records, and patient cases to determine the medical necessity, appropriateness, and level of care based on established clinical guidelines and payer requirements. The role works closely with healthcare providers, payers, and internal teams to support appropriate utilization of healthcare services while ensuring compliance with clinical and regulatory standards.

Key Responsibilities

• Conduct utilization review of inpatient and/or outpatient cases to determine medical necessity and appropriateness of services.
• Review medical records, clinical documentation, treatment plans, and other relevant patient information.
• Apply established clinical criteria and evidence-based guidelines such as InterQual, MCG, or other payer-specific criteria.
• Determine the appropriate level of care, length of stay, and continued stay based on the patient's clinical condition.
• Identify cases that require additional clinical information or physician review.
• Collaborate with physicians, nurses, case managers, and other healthcare professionals regarding utilization decisions.
• Perform concurrent, retrospective, and/or prospective reviews as assigned.
• Facilitate physician-to-physician or peer-to-peer discussions when required.
• Communicate authorization decisions and clinical recommendations accurately and professionally.
• Identify potential overutilization, underutilization, gaps in care, and opportunities for appropriate resource utilization.
• Ensure all reviews and documentation are completed accurately and within required turnaround times.
• Maintain compliance with HIPAA, payer policies, regulatory requirements, and organizational standards.
• Document clinical findings, review outcomes, and recommendations in the appropriate systems.
• Meet established productivity, quality, accuracy, and turnaround-time targets.
• Participate in audits, calibration sessions, training, and process improvement initiatives.

Qualifications

• Must be a Registered Nurse (RN) in the Philippines.
• Preferably with a valid and active USRN license.
• With 2–3 years of clinical experience, preferably in hospital, utilization management, utilization review, case management, or related healthcare settings.
• Experience in US healthcare, health insurance, medical necessity review, or clinical documentation is an advantage.
• Familiarity with InterQual, MCG, or other utilization management guidelines is preferred.
• Strong clinical assessment and critical-thinking skills.
• Excellent verbal and written English communication skills.
• Strong attention to detail and documentation skills.
• Comfortable working with electronic medical records and multiple healthcare systems.
• Willing to work night shift and/or shifting schedules.
• Willing to work onsite, depending on the account requirement.