Company: CORE OBJECTIVE SOLUTIONS, LLC (USA) / CORE CLINICAL SERVICES (INDIA)Shift: Candidate should be ready for adaptable shifts (depend on work )Experience: Minimum 2-3 years in UM Review
About the Role
CORE OBJECTIVE SOLUTIONS, LLC (USA) / CORE CLINICAL SERVICES is hiring Clinical Utilization Review & Management Specialists to support US healthcare clients from our India operations.
This role is ideal for Doctors (BAMS, BHMS) and Nursing Graduates (B.Sc Nursing) who have hands-on experience in Utilization Review (UR/UM) and are comfortable working with US clinical guidelines such as InterQual and MCG.
This is a non-patient-facing, clinical decision support role, focused on reviewing medical cases for medical necessity, appropriateness of care, and compliance with US healthcare standards.
Key Responsibilities
· Perform Utilization Review activities including Pre-Authorization, Concurrent, and Retrospective Reviews
· Evaluate medical necessity and level of care using InterQual and/or MCG guidelines
· Apply sound clinical judgment to approve cases or escalate to Physician Advisors when required
· Ensure reviews are completed within defined turnaround times (TATs) and client SLAs
· Accurately document all decisions and rationale in Utilization Management systems
· Follow HIPAA, client policies, and regulatory guidelines at all times
· Participate in quality reviews, audits, training sessions, and team meetings
· Collaborate with internal clinical, quality, and operations teams to ensure smooth case flow
· Good exposure to denial management and appeals writing is important.
Eligibility & Qualifications
Education
· BAMS/ BHMS / B.Sc Nursing from a recognized institution
· Valid Indian professional registration/license
· We require pune based candidates only.
Experience
· Minimum 2-3 years of Utilization Review / Utilization Management experience with some exposure to Ap