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:

• You have at least 2 years experience including solid experience in a similar role within Healthcare and Bedside experience
• You have working knowledge of Pharmacist and Nursin
• You are adaptable and thrive in changing environments
• You are a strong team player who can manage multiple stakeholders
• You pay strong attention to detail and deliver work that is of a high standard

What's on Offer?

• Join a well known brand within Hospital / Health Care / Healthtech
• Flexible working options
• A role that offers a breadth of learning opportunities