Registered Nurse (PH)

The Role :

PHRN – Job Description

Position : Philippine Registered Nurse (PHRN)

Industry : Healthcare / BPO

Work Type : Onsite / Hybrid / Remote (depends on account)

Shift : Mostly Night Shift (US Healthcare Account)

Job Summary :

The PHRN will support US-based healthcare operations by reviewing clinical cases, processing claims, conducting utilization review, and ensuring medically appropriate and cost-effective care decisions. The role requires strong clinical judgment, excellent communication skills, and accurate documentation.

Key Responsibilities :

• Review medical records, clinical notes, and supporting documents to determine medical necessity and appropriateness of care.
• Process claims, pre-authorizations, and appeals based on established clinical guidelines and payer policies.
• Evaluate patient eligibility, benefits coverage, and required approvals.
• Conduct utilization review using tools such as MCG or InterQual (depending on account).
• Coordinate with healthcare providers, physicians, and insurance representatives regarding care plans, denials, and follow-ups.
• Prepare clear, accurate, and professional clinical documentation and rationales.
• Identify discrepancies in claims, coding issues, or billing irregularities.
• Maintain compliance with HIPAA, company policies, and clinical standards.
• Perform case management or care coordination tasks as needed.
• Participate in training, quality audits, and continuous improvement initiatives.

Ideal Profile :

What's on Offer?