MDS Utilization Review Nurse (US Healthcare)

ISTA Solutions is currently looking for experienced PHRN who have previous experience dealing with US Healthcare Insurance accounts, particularly in Utilization Management. This position entails semi-back-office work dealing with US-based Clients related to Claims, Benefits, Eligibility, Appeals, Prior Authorization, and particularly in MDS Utilization Review .

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.

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Benefits

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