Prior Authorization Nurse

Job Title:  Prior Authorization Nurse

Work Location: Vertis North, Quezon City
Work Setup: Onsite
Work Shift: US Day Shift
Program: Healthcare – Hybrid Voice and Back-Office Operations
Experience: 1–2+ years of relevant clinical and/or Utilization Management experience
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Job description : 

We are looking for a qualified US Registered Nurse (USRN) to join our healthcare team as a Clinical Utilization Management Nurse Specialist. In this role, you will review prior authorization and concurrent review requests, assess medical necessity, and determine the appropriate level of care using established clinical guidelines. You will collaborate with healthcare providers and internal teams to support timely, appropriate, and cost-effective care within a US managed care environment.

Key Responsibilities :

1. Review prior authorization and concurrent review requests to assess medical necessity and determine the appropriate level of care.

2. Coordinate with healthcare providers and internal teams to ensure timely case resolution and support discharge planning and transfer authorization workflows.

3. Escalate cases requiring additional clinical judgment or higher-level review to Medical Directors.

4. Document clinical findings, review outcomes, and case decisions accurately according to established standards.

5. Provide guidance to healthcare providers and internal teams on Utilization Management processes and applicable clinical guidelines.

Required Skills :

1. Active, unrestricted USRN license with NCLEX passed.

2. Knowledge of Utilization Management (UM), Utilization Review (UR), Prior Authorization, or Concurrent Review.

3. Understanding of Medicare, Medicaid, and US managed care fundamentals.

4. Strong clinical assessment, analytical, documentation, and communication skills.

5. Familiarity with InterQual, MCG, or similar clinical decision-support tools is an advantage.

Qualifications : 

• Bachelor of Science in Nursing (BSN) from an accredited nursing school.

• Active, unrestricted US Registered Nurse (USRN) license and successful completion of the NCLEX.

• Healthcare BPO or healthcare payer experience is preferred.

• Willing to work onsite at Vertis North, Quezon City, on a US day shift.

• Must be available to start on or before December 15, 2026.