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 protocols
- Clinical 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 Certification
- Good working knowledge with Clinical Appeals and Revenue Cycle Management
- Excellent verbal and written English skills
- Willing to work onsite in Buendia, Makati
- Amenable working night shifts
Benefits
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