Utilization Review Nurse - IP & OP

Discover your 100% YOU with MicroSourcing!

Position: Utilization Review Nurse - IP & OP
Location: BGC, Taguig City
Work setup & shift: Onsite | Night shift

Sign-on bonus: 50,000*

Why join MicroSourcing?

You'll have:

• Competitive Rewards: Enjoy above-market compensation, healthcare coverage on day one, plus one or more dependents, paid time-off with cash conversion, group life insurance, and performance bonuses
• A Collaborative Spirit: Contribute to a positive and engaging work environment by participating in company-sponsored events and activities.
• Work-Life Harmony: Enjoy the balance between work and life that suits you with flexible work arrangements.
• Career Growth: Take advantage of opportunities for continuous learning and career advancement.
• Inclusive Teamwork: Be part of a team that celebrates diversity and fosters an inclusive culture.

Your Role
The Utilization Review Nurse - IP & OP is responsible for reviewing the claims denied and carrying out the appeals process appropriately and in a timely manner. This individual identifies and works on denials, responding to the denial reason and resubmitting any information needed to the payor. The Clinical Denials and Appeals Specialist should be knowledgeable of U.S. state/federal laws that relate to payor contracts and to the appeals process. This role requires frequent and effective communication via phone, email, and instant messaging with the various engagement teams. Strong oral and written communication skills, analytical skills, ability to work independently, and self-motivation are required.

As a Clinical Denials & Appeals Nurse Specialist – IP & OP, you will:

Denials and Appeals Management

• Work denials and appeals timely, evaluating the denial reason, including information from the payor and payor policies, reviewing the clinical documentation, assessing options, and completing next steps
• Submit retro-authorizations in accordance with payor requirements in response to authorization denials
• Conducts medical necessity reviews, based on the denial root cause, and prepares any required clinical documentation summaries to accompany appeals.
• Write and submit written appeals that include compelling arguments based on clinical documentation, third-party payer medical policies, and contract language. Appeals are submitted timely and tracked through the final outcome.
• Document all actions taken and follow up timely as needed related to resolving denials and appeals with third-party payers in a timely manner
• Track the status and progress of denials and appeals
• Completes relevant research to assist with completing the appeals process and to stay informed on best practices and policy reforms
• Executes internal and external correspondence accurately, clearly, concisely, and professionally while following organizational regulations
• Effectively handles all communications, including telephone, electronic, and paper correspondence from payers and departments within the business office

Tracking, Reporting, and Trends

• Maintain data on the types of claims denied and the root causes of denials
• Identify denial patterns and escalate to management as appropriate with sufficient information for additional follow-up, and/or root cause resolution
• Collaborate with management to recommend process changes to address the root cause of denials and overall improvement to reduce A/R
• Prepares, maintains, assists with, and submits reports as required

Compliance and Continuous Improvement

• Collaborate with team members to continually improve services, and engage in process and quality improvement activities
• Identify system improvement opportunities and contribute to the testing of system modifications
• Conducts relevant research to assist with completing the appeals process and to stay informed on best practices and policy reforms
• Complies with state and federal regulations, accreditation/compliance requirements, and Huron’s policies, including those regarding fraud and abuse, confidentiality, and HIPAA
• Maintains a thorough understanding of federal and state regulations, as well as specific payer requirements and explanations of benefits, in order to identify and report billing compliance issues and payer discrepancies
• Participates in ongoing professional development to enhance job knowledge and performance
• Reports all identified compliance risks to appropriate leadership

Other duties and responsibilities as assigned.

What You Need
Non-negotiables

• Clinical Appeals Experience: At least 1 year of clinical appeal writing experience.
• Clinical Experience: Minimum of 3-5 years acute care clinical experience in a hospital setting (Med/Surg, or similar preferred); 2-3 years of ICU experience.
• Education: Bachelor of Science in Nursing.
• Licensure: Must be a Registered Nurse with an active PHRN or USRN license.
• RCM Knowledge: Proficiency in using InterQual or MCG clinical guidelines. Broad Knowledge of U.S. Government Programs and Insurance Regulations
• Software Knowledge: Proficiency with hospital-based electronic medical records (EMR) such as Epic, Cerner, or Meditech.
• Excellent verbal and written English communication skills and customer service skills (CEFR level of at least B2 for both verbal and written)

Preferred skills/expertise

• Education: Master’s degree or credential in business, healthcare, or related field preferred
• Credential/Certification: Case management, clinical appeals, or clinical denials certification (ACMA) is preferred.
• Software Knowledge: Proficiency in using computer programs for tracking denials and appeals. Proficiency with Microsoft Office suite (Excel, Word, PowerPoint, Outlook, SharePoint)

Soft Skills:

• Ability to pay close attention to details; strong follow-up and follow-through skills
• Regularly makes complex decisions within the scope of the position, and is comfortable working independently
• Requires the use of independent judgment, discretion and decision-making abilities
• Demonstrates teamwork and integrity in all work-related activities
• Ability to interact with internal and external customers in a professional manner
• Strong analytical and critical thinking skills.
• Experience in a matrixed environment
• Excellent written and verbal communication skills

About MicroSourcing

With over 9,000 professionals across 13 delivery centers, MicroSourcing is the pioneer and largest offshore provider of managed services in the Philippines.

Our commitment to 100% YOU

MicroSourcing firmly believes that our company's strength lies in our people's diversity and talent. We are proud to foster an inclusive culture that embraces individuals of all races, genders, ethnicities, abilities, and backgrounds. We provide space for everyone, embracing different perspectives, and making room for opportunities for each individual to thrive.

At MicroSourcing, equality is not merely a slogan - it's our commitment and our way of life. Here, we don't just accept your unique, authentic self—we celebrate it, valuing every individual's contribution to our collective success and growth. Join us in celebrating YOU and your 100%!

For more information, visit www.microsourcing.com

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