Utilization Review Nurse, USRN - Prior Authorization

Role Overview :

We are seeking a skilled Utilization Management / Review Nurse to join our team. This role is essential in ensuring patients receive appropriate, timely, and cost-effective care by reviewing medical records, treatment plans, and healthcare resource utilization.

Key Responsibilities :

Conduct concurrent and retrospective reviews of patient clinical information to ensure medical necessity, appropriateness, and efficiency of services.

Review precertification and authorization requests for inpatient and outpatient care against established clinical guidelines and payer policies.

Collaborate with physicians, case managers, and healthcare professionals to coordinate care and discharge planning.

Analyze utilization trends and identify opportunities for improving resource use and cost-effectiveness while maintaining quality care.

Maintain accurate documentation of all utilization review activities and patient interactions.

Provide daily updates and reports to the Utilization Management Manager.

Educate healthcare staff and providers on utilization management policies and best practices.

Ensure compliance with regulatory requirements and internal policies related to utilization management.

Serve as a patient advocate to promote appropriate care and prevent unnecessary hospitalizations or procedures.

Qualifications :

Graduate of BS Nursing with an active USRN license.

At least 2-4 years of solid experience in Utilization Review and Management.

Prior hospital experience, preferred

Strong knowledge of clinical guidelines and medical necessity criteria is preferred (MCG / Interqual, etc.)

Excellent analytical, organizational, and communication skills.

Ability to work independently in a fast-paced environment.

Willingness to work onsite in Ortigas and on a night shift schedule.

Utilization Management or Case Management certification is a plus.

Perks and Benefits :

15% Night Differential

HMO coverage after 30 days of employment (with option to add up to 2 dependents)

Retirement Benefits

24 Leave Credits per year (convertible to cash)

Wholistic Employee Wellness Program

Why Join Visaya KPO?

Be part of a multi-awarded, 100% Filipino-owned company recognized for its leadership and innovation in the outsourcing industry1.

Work in a culture that values professional growth, employee well-being, and long-term partnerships.

Enjoy industry-leading benefits and a supportive, inclusive environment.

Visaya KPO is an equal opportunity employer. We celebrate diversity and are committed to creating an inclusive environment for all employees.

#visayajobs

Job Type : Full-time

Benefits :

Company Christmas gift

Company events

Health insurance

Opportunities for promotion

Paid training

Promotion to permanent employee

Ability to commute / relocate :

Ortigas : Reliably commute or planning to relocate before starting work (Required)

Experience :

Prior Authorization : 2 years (Preferred)

Hospital : 2 years (Preferred)

License / Certification :

USRN license (Required)