Utilization Review Nurse

Ready to make an impact? At Hive Health, we’re on a mission to make healthcare radically more accessible for all—and we need passionate, driven individuals to help us make it happen. If you thrive in a fast-paced, innovative environment and want to work on solutions that truly matter, we’d love to meet you!

Job Summary

The Utilization Review Nurse serves as the key interface between members, healthcare providers, and the HMO teams.

The role is responsible for accurate processing of member availments, issuance of Letters of Authorization (LOAs), timely call handling, and efficient coordination of inquiries and cases to ensure high-quality service delivery.

Responsibilities

1. Accurate and Efficient Adjudication of Member Availments and Issuance of LOA’s

• Review and process member availments and claims in accordance with company policies, HMO guidelines, medical indication, and PhilHealth regulations.

• Ensure Letters of Authorization (LOAs) are accurately prepared, approved, and issued in a timely manner or within ideal standards.

• Identify and resolve problems concerning availments and LOA issuances to members.

• Maintain complete and accurate data recording for auditing and utilization capture.

• Discharge members efficiently ensuring all documentations and computations are complete and accurate.

1. Maintain Effective Call Handling and Timely Log-in

• Respond promptly and professionally to inbound calls from providers.

• Provide accurate information regarding availments, benefits, and LOA’s.

• Maintain daily log-in and call handling metrics in line with departmental standards.

• Follow up on inquiries or escalated cases to ensure timely resolution.

3. Efficient Handling and Coordination of Inquiries and Cases

• Serve as the main point of contact for providers regarding availments, LOAs, and member concerns.

• Coordinate with healthcare providers and internal departments to resolve members’ inquiries and concerns

• efficiently.

• Track the progress of cases and ensure timely resolution.

• Document interactions, updates, and outcomes in the concerned channels.

Qualifications

• Must be willing to work hybrid in Ortigas

• Must be willing to do occasional night shifts

• Familiarity with medical indications for adjudication

• Prior experience in roles such as medical liaison, provider relations, hospital HMO section staff, company nurse, teleconsult nurse, etc., is advantageous

• Willingness to conduct hospital visits

• Proficient problem-solving abilities

• Curious, results-driven, ownership mentality with growth mindset

• Excellent verbal and written communications

• Collaborative team player with the ability to adapt quickly in a fast-paced environment

• Passion for innovation in healthcare

Join our team as we revolutionalize healthcare in the Philippines—and beyond!