Utilization Review Nurse (USRN)

About the role

The Utilization Review Nurse performs medical necessity reviews for a US healthcare client. You will review prospective (prior authorization), concurrent (inpatient stay), and retrospective (post-discharge) cases, including treatments, procedures, hospitalizations, home care, and inpatient/outpatient treatment plans. Reviews follow InterQual or MCG criteria, the client's contract rules and guidelines, and company policies to support quality, cost-effective care.

Key responsibilities

• Review prior authorization requests for procedures, tests, and admissions
• Conduct daily concurrent reviews and recommend the right level of care
• Audit completed cases and support denial and appeal reviews
• Escalate cases that do not meet criteria to physician reviewers
• Coordinate with US providers, case managers, and payers by phone and message
• Meet turnaround, productivity, and quality targets
• Protect patient information under HIPAA and the Philippine Data Privacy Act

About you

• Active US RN license (mainland state) – required
• Active PRC nursing license and BSN degree
• At least 2 years of recent acute care hospital/bedside experience (ICU, ER, med-surg, OR, or step-down preferred)
• Excellent English communication and documentation skills
• Willing to work night shift (US hours)
• At least 1 year of recent Utilization Review/Management experience (preferred)
• Hands-on experience with InterQual or MCG criteria (preferred)
• CCM (Certified Case Manager) or CPUR certification (preferred)
• Experience on a US healthcare BPO/CPO account (preferred)