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

Benefits

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