Job Title: Health Clinical Services Senior Manager – USRN

Work Setup: Onsite

Location: Uptown Bonifacio, Taguig

Work Schedule: Night Shift | Weekends Off

Job Summary:

We are seeking an experienced US Registered Nurse (USRN) to lead clinical review operations and manage high-performing healthcare teams. This role oversees utilization management, medical necessity reviews, and claims analysis while ensuring compliance with US healthcare standards and policies.

Key Responsibilities:

• Lead and oversee clinical teams performing utilization and medical necessity reviews
• Review pre-service, concurrent, retrospective, and out-of-network cases
• Ensure compliance with medical policies, benefits, and member eligibility
• Oversee post-service and pended claims review
• Coordinate with healthcare providers to obtain required clinical information
• Maintain quality, accuracy, and regulatory compliance across all reviews

Qualifications & Requirements:

• Active and unrestricted USRN license (any US state)
• Minimum 12 years of clinical experience
• At least 10 years of supervisory or leadership experience
• Open to both BPO and non-BPO backgrounds
• Must have the right to live and work in the Philippines
• No active or recent application with the same employer
• Stable employment history (no frequent job changes)

Additional Notes:

• Onsite role based in Taguig
• Night shift schedule with weekends off
• Salary details to be discussed during the selection process