PHRN - Utilization Review / Clinical Authorization

24 hours 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, Taguig
Schedule: Night Shift | Monday to Friday
Hiring 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
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