A
AGS Health Philippines, Inc
Utilization Review Nurse (PHRN)
Skills
Compliance
2 months ago
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Important information
Contract type:
Permanent
Location:
Taguig, Metro Manila, Philippines
Work mode:
Onsite
Published on:
18 August 2026
What they need
- Provide healthcare utilization review services regarding admissions, observations, and discharge work queues (WQs) based on payer types and review types.
- Review admissions and service requests within the assigned unit for prospective, concurrent, and retrospective medical necessity and/or compliance with reimbursement policy criteria.
- Assist with issues related to coding, medical records/documentation, precertification, reimbursement, and claim denials/appeals.
- Notify attending physicians and other members of the healthcare team of inappropriate admissions, denials, end of authorized days, or other factors that may impact reimbursement.
- Consult with attending physicians when documentation in the medical record does not support admission or continued stay, and work to ensure the completeness of all clinical documentation.
- Function as a liaison between the Physician Advisor and the attending physician.
- Document denial information in the electronic medical record system, including attempts at resolution or overturning the denial.
- Provide all payer communications for scanning into the system for use in appeals.
- Apply MCG and InterQual guidelines for each case review to determine the appropriate status.
- Consult with medical and treatment staff regarding client diagnoses, medical justification, length of treatment, and case documentation.
- Participate in utilization and peer review meetings and projects.
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