PHRN Utilization Reviewer (MDS) | Get a 21K Signing Bonus

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