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.

Job Description:

• 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.

• With proven clinical work experience (1 - 2 Years)

• At least 6 months US Healthcare background

• Nurse who worked in an Inpatient SNF/Post Acute care services 

• Must have experience regarding MDS (Minimum Data Set)

• Must have an active PHRN license (USRN license is a PLUS)

• Excellent verbal and written English skills

• Willing to work onsite in Buendia, Makati

• Amenable working night shifts

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

Please refer to job description.