USRN - Health Clinical Services Senior Manager

Gratitude Inc

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2 days ago

USRN - Health Clinical Services Senior Manager

10-12 Year(s)

150 - 200 Thousand p.m

Manila (Taguig)

Job Description

Key Skills

USRN Utilization Review Supervisory Experience

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We are seeking an experienced healthcare leader to manage our clinical review operations. The ideal candidate will bring deep expertise in utilization management, claims review, and team leadership within a regulated healthcare environment.

Responsibilities:

Lead and supervise a team responsible for clinical review operations, ensuring compliance with medical policy, eligibility, benefits, and contractual guidelines.

Oversee a range of review activities, including pre-service, concurrent, retrospective, out-of-network, and treatment setting appropriateness reviews.

Manage the processing of service requests received via inbound calls and facsimile.

Ensure team members conduct necessary outbound calls to healthcare providers to gather supplemental clinical information.

Supervise the post-service claims review process, analyzing claims against member benefit contracts and organizational health plan guidelines.

Direct the completion of post-service pended claims reviews for both Medical Necessity and Contractual compliance.

Qualifications & Skills:

Minimum of 12 years of relevant experience in healthcare utilization management, clinical review, or a closely related field.

At least 10 years of demonstrated supervisory or team leadership experience.

Must possess a current and unrestricted US Registered Nurse license (no specific state licensure required).

Experience in a Business Process Outsourcing (BPO) environment is acceptable; health account experience is advantageous but not mandatory.

Open to candidates with diverse professional backgrounds from both BPO and non-BPO settings.

Applicants must be currently located in the Philippines and possess the legal right to live and work in the country without sponsorship.

Candidates must not have applied for any other role with our organization within a recent, specified period.

We seek candidates with a stable employment history, demonstrating commitment in previous roles.

If your skills and experience align with this profile, we encourage you to apply.

Role

Medical Administrator

Timings

Night Shift (Permanent)

Industry

Medical / Healthcare / Hospital

Work Mode

Work from office

Functional Area

Medical Professional / Healthcare Practitioner / Technician

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