Utilization Review Nurse

About the role

The Utilization Review Nurse will manage denied claims and lead the appeals process for third‑party payers. Working night shifts onsite in BGC, Taguig City, you will ensure timely resolution of denials by reviewing clinical documentation, applying relevant payer policies, and preparing compelling appeals.

Key responsibilities

• Evaluate claim denials, identify root causes, and submit required retro‑authorizations.
• Conduct medical necessity reviews and prepare clinical summaries for appeals.
• Write and submit written appeals that reference clinical evidence, payer policies, and contract language.
• Track appeal status, document all actions, and follow up to achieve final outcomes.
• Maintain data on denial types and trends, and stay updated on best practices and policy reforms.
• Communicate effectively with internal teams and external payers via phone, email, and instant messaging.

Required profile

• Strong oral and written communication skills.
• Analytical mindset with the ability to work independently and stay self‑motivated.
• Knowledge of U.S. state and federal laws related to payer contracts and appeals.
• Experience reviewing clinical documentation and medical necessity.

Required skills

What we offer

• Sign‑on bonus of 50,000 (subject to conditions).
• Above‑market compensation, healthcare coverage from day one, and benefits for dependents.
• Paid time‑off with cash conversion, group life insurance, and performance bonuses.
• Collaborative work environment with company‑sponsored events.
• Flexible work arrangements to support work‑life harmony.
• Opportunities for continuous learning, career advancement, and an inclusive culture.