Utilization Reviewer

UST HealthProof is a trusted partner for health plans, offering an integrated ecosystem for health plan operations. Our BPaaS solutions manage complex admin tasks, allowing our customers to prioritize members' well-being. With our commitment to simplicity, honesty, and leadership, we navigate challenges with our customers to achieve affordable health care...

Responsibilities:Develop full understanding of each medical and claim payment policy, to ensure accurate diagnosis and procedure code assignment. Understand CMS/regulatory requirements, IBX/AH benefit structure, managed care rules (e.g., HMO Capitation, PPO Network Rules) and other business rules to assure diagnosis and procedure code alignmentReal-time...

California Water ServiceJob Description:The position is responsible for planning, designing, and delivering capital projects. These projects include wells, storage tanks, pump stations, pressure tanks, pipelines and treatment plants. Projects may be new installations or modifications to existing facilities. This position is located in Chcio,...

Position SummaryDrive, lead and support the team for control assurance activities. Provide expertise in crafting and delivering assurance on Non financial key controls. This role will need to co-ordinate with a set of Control owners/risk managers/champions in respective business verticals where the controls are owned. The team will be part of central Control...

We are looking for a Security Operations Center (SOC) Analyst who will be responsible for monitoring, detecting, analyzing, and responding to cybersecurity incidents across the organization's IT environment. You'll play a key role in safeguarding systems, networks, and data by ensuring timely detection and mitigation of potential threats. Work Setup: Full...

We are seeking a Data Specialist who is highly detail-oriented and skilled in data reporting and analysis. This role involves generating, reviewing, and maintaining accurate daily data reports to support the company's operations. The ideal candidate must be proficient in Microsoft Excel, particularly in using formulas and data functions, to ensure accuracy,...

Position Title: PHRN Quality Auditor - Prior/Clinical AuthorizationLocation: McKinley, TaguigWork Set-up: Full Onsite | Night ShiftDirect Hire | Permanent role Qualifications: Must hold an active PHRN license With relevant experience as a Quality Auditor in Clinical Services within a healthcare BPO environment Open for Associate/CSR with 4+ years of...

Responsible for the accurate review/audit of medical claims based defined claims guidelines and policies.Review claims or modifies existing claims according to the appropriate and applicable actionAnalyze claims to determine appropriate action to approve or deny action done by the agentDetermine if accurate payment criteria for clearing pending claims based...

The Resource Manager is responsible for optimizing workforce deployment and ensuring a positive employee experience. This role is also responsible for the seamless coordination of resource allocation, onboarding, performance management, and employee relations within assigned accounts. The Resource Manager acts as a key liaison between employees, clients, and...

General Responsibilities:As a Cloud Engineer, you'll design, build, and manage secure and scalable cloud infrastructure across platforms (Azure/AWS/GCP/Alibaba) while optimizing applications for the cloud, ensuring seamless migration and ongoing performance. The role involves coding, handling deployments, configuring cloud infrastructure, staying updated on...