PHRN - Utilization Review / Clinical Authorization

3 weeks ago

Taguig, Philippines HRTX Full time

About the job PHRN - Utilization Review / Clinical Authorization We're Hiring: PHRN Quality Auditor Clinical Services Location: Onsite, Mckinley, TaguigSchedule: Night Shift | Monday to FridayHiring Target Date: Preferably by July 21, 2025 Salary Range: Up to 50k Qualifications Must hold an active PHRN license (Not a USRN holder)Prior experience as a Quality Auditor in a healthcare BPO clinical setting Alternatively, 4 to 7 years of specialized experience in Clinical Authorization or Utilization Review Strong knowledge of EPIC , MCG , or InterQual guidelines Must have a stable work history with minimal employment transitions Key Responsibilities I. Quality Auditing Conduct audits in accordance with Quality Improvement Plans (QIP) Provide actionable feedback to team members and track corrections Escalate compliance concerns, trends, and anomalies to leadership Stay updated through production work and active participation in process updates Join client calls to ensure accurate capture of updates and compliance II. Clinical Process Management Verify patient insurance eligibility, benefits, and requirements with payers Request, track, and secure pre-authorizations for medical services and procedures Review and follow up on oncology chemotherapy drug authorizations Ensure HIPAA compliance and maintain proper documentation in EHR Handle medical necessity documentation and assist in denial appeals Prioritize cases based on urgency and patient impact Communicate with insurance companies, healthcare providers, and patients as needed Address clinical inquiries based on payer medical policy guidelines #J-18808-Ljbffr

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