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PHRN - Prior Authorization

Quality Auditor hiring Clinical Authorization Process.

Onsite, Night Shift, Mon-Friday

Qualifications

Must hold an active PHRN license (not a USRN license holder)
Relevant experience as a Quality Auditor in Clinical Services within a healthcare BPO environment; alternatively, 4 to 7 years of specialized experience in Clinical Authorization or Utilization Review is preferred
Strong familiarity with EPIC, MCG, or InterQual guidelines required
Demonstrated job stability, with a consistent employment history and minimal transitions

Job Description

I. Audit

Completing QA audits for their processes by following the QIP
Providing feedback to team members on all errors
Escalating any anomalies / trends / Compliance issues
Performing the actual production work to keep abreast of the latest updates and practical scenarios
Participating in client calls to capture process updates and monitoring compliance to the updates

II. Process

Contact insurance carriers to verify patients insurance eligibility, benefits, and requirements.
Request, track, and obtain pre-authorization from insurance carriers within time allotted for medical and services.
Review, request, follow up and secure authorizations for high dollar cost oncology chemotherapy drugs.
Demonstrate and apply knowledge of medical terminology, high proficiency of general medical office procedures including HIPAA regulations.
Assist with medical necessity documentation to expedite approvals and ensure that appropriate follow-up is performed.
Review denials and follow up with provider to obtain medically necessary information to submit an appeal of the denial.
Prioritize the incoming authorizations by level of urgency to the patient.
Manage correspondence with insurance companies, physicians, specialists, and patients as needed, including documenting in the EHR as appropriate.
Respond to clinical questions regarding payer medical policy guidelines

Talent Job Seeker
Taguig
app.general.countries.Philippines

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Job ID: 9711528 / Ref: c31c5c469efc4f6fce59c9365341e58c