USRN / US Registered Nurse - Trainer, QA , Clinical Appeals , UMR
About the role
Nezda Technologies, Inc. is seeking a USRN / US Registered Nurse - Trainer, QA, Clinical Appeals, or UMR to join our healthcare operations team. This is a full-time position based in Metro Manila. In this strategic role, you will serve as a bridge between clinical excellence and operational quality, leveraging your nursing expertise to train staff, ensure quality standards, manage clinical appeals, and oversee utilization management review processes.You will play a crucial role in maintaining the highest standards of patient care and regulatory compliance across our organization.
Key responsibilities
- Develop, deliver and continuously update comprehensive training programmes for clinical and non-clinical staff on medical-surgical nursing practices, quality standards and compliance requirements
- Manage and adjudicate clinical appeals, ensuring thorough review of medical necessity decisions and appropriate escalation procedures
- Oversee utilisation management review (UMR) processes, including pre-authorisation and retrospective review of healthcare services
- Provide clinical expertise and evidence-based recommendations to support decision-making across appeals and utilisation review cases
- Mentor and coach team members on clinical best practices, ethical considerations and regulatory requirements
- Collaborate with healthcare providers, clinical teams and administrative departments to address concerns and implement improvements
- Maintain detailed documentation and generate reports on training activities, quality metrics and appeals outcomes
- Stay current with healthcare regulations, industry standards and clinical developments relevant to nursing practice
- Support the development and implementation of clinical policies and procedures
- Current, valid US Registered Nurse (RN) license with active registration
- Minimum 1-3 years of post-licensure hospital setting experience in
- Proven experience in clinical training, quality assurance, peer review or utilization management within a BPO or CPO healthcare setting
- Strong knowledge of healthcare regulations, including HIPAA, accreditation standards and managed care requirements
- Excellent communication skills, both written and verbal, with the ability to explain complex clinical concepts clearly to diverse audiences
- Proficiency in electronic health records (EHR) systems and healthcare information technology platforms
- Demonstrated ability to work independently whilst collaborating effectively within a team environment
- Strong analytical and critical thinking skills with meticulous attention to detail
- Professional certifications such as Certified Case Manager (CCM), Certified Healthcare Quality Association (CHQA) or similar qualifications are highly desirable but not required
- Experience with telehealth, remote case management or appeals processes is advantageous
- Willingness to work in a temporary remote or hybrid arrangement within Metro Manila (DEPENDS ON THE POSITION)
Our company culture prioritises collaboration, continuous learning and professional growth. We provide comprehensive health and wellness support for our employees and foster an inclusive workplace where diverse perspectives are valued. Additional benefits include performance-based incentives and the opportunity to make a meaningful impact in healthcare quality and patient care outcomes.
About us
We are a forward-thinking healthcare technology and services organization dedicated to delivering innovative solutions that improve patient outcomes and streamline healthcare operations. Our mission is to bridge the gap between clinical excellence and operational efficiency through technology, training and quality assurance. We work closely with healthcare providers, managed care organizations and patients to ensure that quality care is accessible, affordable and compliant with the highest standards.Our values center on integrity, patient-centered care, continuous improvement and professional excellence. We are committed to building a workplace culture that celebrates innovation, supports professional development and recognizes the vital contributions of our healthcare professionals.