Utilization Review Nurse | UMR | PHRN | Pasay

We are seeking a highly skilled and detail-oriented PH Registered Nurse (PHRN) to join our team.

The ideal candidate will have hands-on experience with InterQual, MCG , NCD, and LCD Guidelines

• Conduct clinical reviews of inpatient and outpatient services using InterQual, MCG, NCD, and LCD criteria.
• Analyze patient records to determine the medical necessity and appropriateness of services.
• Collaborate with medical directors and multidisciplinary teams to review complex cases.
• Ensure compliance with regulatory and payer-specific guidelines.
• Document and maintain accurate and comprehensive review records.
• Participate in quality improvement and audit initiatives.

• Active PHRN license
• at least 1 year of clinical nursing experience in utilization review or case management experience preferred.
• Must have minimum acute bedside experience
• Proficient in using InterQual and MCG guidelines.
• Strong working knowledge of NCD and LCD criteria and application.
• Experience in developing or implementing clinical decision trees or algorithms.