About this role
ISTA Solutions, an outsourcing/offshoring company, is in search of a Utilization Reviewer to join our rapidly expanding team. As a member of our team, you will have the opportunity to work with highly skilled professionals, who prioritize employee satisfaction and work-life balance. At ISTA Solutions, we pride ourselves on creating a culture focused on long-term success and life-long learning. We're looking for a team player who is ready to contribute to our mission, just like you!
Account specific roles and responsibilities:
Performs Utilization Management (UM) Reviews in accordance with US State/Federal and other mandated regulations. Maintains compliance with regulatory changes affecting UM.Performs UM reviews (Prospective/Concurrent/Retrospective) for inpatient services according to the prescribed standards and client requirements and/or policies. Reviews UM request for services against established clinical review criteria, referring cases not meeting criteria to a physician reviewer or prescribed escalation protocol.Coordinates physician reviewer or MDS/Facility - Nurse Practitioner as needed and follows up timely to obtain and deliver those information or result. Tracks status of all UM in progress.Releases UM determinations to claim/Authorization stakeholders following client -established protocols. Maintains all required UM review documentation in the UM software in timely manner.Responds to inbound telephone calls pertaining to UM reviews in a timely manner, following client-established protocolsClinical interface/liaison (Clinical problem solver with facilities, provider, carriers; resolution of issues concerning members, benefit interpretation, program definition and clarification.Clinical Operations Analysis - Monitor and analyzes medical management activities; provides analytical support to clinical programs; may perform clinical assessment and clinical audits.Requirements
6 months - 1 year experience in Utilization Reviewer / Clinical Nurse Reviewer for a US Healthcare account Must have experience regarding MDS (Minimum Data Set) Must have an active PHRN license (USRN license is a PLUS)Must have Dialysis Training CertificationGood working knowledge with Clinical Appeals and Revenue Cycle Management Excellent verbal and written English skillsWilling to work onsite in Buendia, Makati Amenable working night shiftsBenefits
What can we offer you?
Competitive salary and benefits Health Insurance with free dependents* 10%-night differential Attendance Bonus Paid time off Convertible to cash leave credits Performance Appraisal Work-life balance A focus on growing your career path with us We encourage you to follow your passions and learn new skills Our commitment to you
Strong culture and values-driven leadership We create opportunities for you to learn and grow at any stage of your career Continuous learning and innovation We foster an all inclusive environment where everyone thrives