Job Title: Clinical Utilization Review & Management Specialist (US Healthcare)

Company: CORE OBJECTIVE SOLUTIONS, LLC (USA) / CORE CLINICAL SERVICES (INDIA)Shift: Candidate should be ready for flexible shifts (depend on work )Experience: Minimum 2-3 years in UM Review

About the Role

CORE OBJECTIVE SOLUTIONS, LLC (USA) / CORE CLINICAL SERVICES is hiring Clinical Utilization Review & Management Specialists to support US healthcare clients from our India operations.

This role is ideal for Doctors (BAMS, BHMS) and Nursing Graduates (B.Sc Nursing) who have hands-on experience in Utilization Review (UR/UM) and are comfortable working with US clinical guidelines such as InterQual and MCG.

This is a non-patient-facing, clinical decision support role, focused on reviewing medical cases for medical necessity, appropriateness of care, and compliance with US healthcare standards.

Key Responsibilities

· Perform Utilization Review activities including Pre-Authorization, Concurrent, and Retrospective Reviews

· Evaluate medical necessity and level of care using InterQual and/or MCG guidelines

· Apply sound clinical judgment to approve cases or escalate to Physician Advisors when required

· Ensure reviews are completed within defined turnaround times (TATs) and client SLAs

· Accurately document all decisions and rationale in Utilization Management systems

· Follow HIPAA, client policies, and regulatory guidelines at all times

· Participate in quality reviews, audits, training sessions, and team meetings

· Collaborate with internal clinical, quality, and operations teams to ensure smooth case flow





· Good exposure to denial management and appeals writing is important.

Eligibility & Qualifications

Education

· BAMS/ BHMS / B.Sc Nursing from a recognized institution

· Valid Indian professional registration/license

· We require pune based candidates only.

Experience

· Minimum 2-3 years of Utilization Review / Utilization Management experience with some exposure to Appeals Writing.

· Overall experience – 3-5 years

· Mandatory experience with InterQual and/or MCG

· Prior exposure to US healthcare processes is required

Skills & Competencies

· Strong understanding of medical terminology, clinical workflows, and treatment protocols

· Ability to interpret clinical documentation and apply evidence-based guidelines

· Good written and verbal communication skills in English

· Comfortable working with clinical documentation tools and healthcare software

· Detail-oriented with robust analytical and decision-making skills

· Ability to work independently in a fast-paced, deadline-driven environment

Work Environment

· Willingness to work US day or night shifts, including rotational schedules if required

· Remote or onsite options based on project requirements

· Strict adherence to confidentiality, data security, and compliance standards

What We Offer

· Excellent salary package with performance-based incentives

· Exposure to leading US healthcare clients

· Structured training on US healthcare guidelines and processes

· Clear growth opportunities paths in Clinical Operations, Quality, Auditing, and Leadership

· Professional and supportive work culture

Work Location: In person

📌 Clinical Utilization Review & Management Specialist (India)
🏢 CORE CLINICAL SERVICES
📍 India