job description
Join our dynamic USRN (Utilization Review Nurse) Team and play a pivotal role in ensuring high-quality, cost-effective healthcare delivery for our US-based clients. As a Utilization Review Nurse, you will collaborate with healthcare providers, insurance companies, and patients to evaluate the medical necessity of treatments, procedures, and hospital stays. This is a dayshift position in a fast-paced, remote Healthcare BPO environment, offering you the opportunity to leverage your clinical expertise while working from the comfort of Bali’s most vibrant locations.
We are seeking licensed US Registered Nurses (USRN) with a passion for patient advocacy and a keen eye for detail. This role is perfect for professionals who thrive in a structured yet flexible setting, where your decisions directly impact patient care and operational efficiency. Enjoy competitive compensation, career growth opportunities, and the chance to be part of a growing international healthcare team.
Responsibility
- Conduct thorough utilization reviews for medical services, including hospital admissions, procedures, and treatments, to determine medical necessity and appropriateness.
- Collaborate with physicians, case managers, and insurance providers to gather clinical information and make informed decisions.
- Apply evidence-based criteria (e.g., InterQual, MCG) to assess patient cases and ensure compliance with healthcare policies and regulations.
- Document detailed findings and recommendations in electronic health records (EHR) and utilization management systems.
- Communicate denial, approval, or modification decisions to healthcare providers and patients with clarity and professionalism.
- Monitor and track utilization patterns to identify trends, reduce unnecessary costs, and improve patient outcomes.
- Stay updated on healthcare laws, insurance policies, and industry best practices to ensure accurate and compliant reviews.
- Participate in team meetings and training sessions to enhance skills and align with organizational goals.
Qualifications
- Active US Registered Nurse (USRN) license in good standing (required).
- Minimum 2 years of clinical nursing experience in a hospital, acute care, or managed care setting.
- Prior experience in utilization review, case management, or insurance is a strong plus.
- Proficiency in using utilization management software (e.g., InterQual, MCG, or similar tools).
- Excellent communication, analytical, and decision-making skills with attention to detail.
- Ability to work independently in a remote setting with a stable internet connection and a quiet workspace.
- Familiarity with US healthcare systems, insurance policies, and HIPAA regulations.
- Willingness to work on a dayshift schedule (aligning with US business hours).