Utilization review and Case management Nurse seeking remote work

Overview

Looking for full-time work (8 hours/day)

at $8.31/hour ($1,600.00/month)

Bachelor's degree

Last Active

June 24th, 2026 (yesterday)

Member Since

February 1st, 2026

Profile Description

USRN Northern Mariana Island: License Number: R190325
Connecticut: License Number: 160034
Texas: License Number: 966301

* Registered Nurse with License No: ---------- , issued by the Professional Regulation
Commission, Manila, Philippines
* Over 5 years experience in various hospital units/ departments
* 2 years of experience in Clinical Process Outsourcing / Nurse Case Manager
* 6 years of experience in Clinical Process Outsourcing / utilization Manager

- Responsible for reviewing, coordinating, and managing the medical necessity and efficiency of healthcare services and hospital admissions. Coordinating and providing care that is safe, timely, effective, efficient, equitable, and client-centered
- Conduct concurrent and retrospective reviews of inpatient and outpatient services for medical necessity, appropriateness, and level of care.
- Apply clinical criteria (e.g., InterQual, MCG, CMS Guidelines) to support utilization decisions.
- Collaborate with physicians and interdisciplinary teams to ensure timely reviews and documentation.
- Initiate and coordinate peer-to-peer reviews when medical necessity is questioned.
- Handling case assignments, draft service plans, review case progress and determine case closure
- Helping clients achieve wellness and autonomy
- Facilitate multiple care aspects (case coordination, information sharing, etc)
- Help patients make informed decisions by acting as their advocate regarding their clinical status and treatment options
- Develop effective working relations and cooperate with medical team throughout the entire case management process
- Take the extra mile and interact with patients to keep track of their progress and to ensure satisfaction
- Record cases information, complete accurately all necessary forms and produce statistical reports
- Promote quality and cost-effective interventions and outcomes
- Assess and address motivational and psychosocial issues
- Adhere to professional standards as outlined by protocols, rules and regulations

I have strong experience reviewing provider requests for medical necessity using tools such as medical policy guidelines and InterQual/MCG criteria. I handle pre-authorizations and concurrent reviews while communicating effectively with physicians regarding appropriate levels of care.

I am detail-oriented when identifying and clarifying documentation gaps, ensuring decisions are well supported and compliant with guidelines. I maintain a calm, professional, and persuasive communication style when collaborating with providers and care teams.

I bring strong clinical judgment and am highly comfortable applying established guidelines and protocols, supported by years of hands-on clinical experience.

I transitioned into Utilization Management to leverage my clinical expertise in a role that is less physically demanding, supports remote work, and offers competitive opportunities within US-based healthcare accounts.