PHRN - Clinical Denials and Appeals

4 days ago

Taguig, Philippines Gratitude Philippines Full time

Work set up: Onsite Opportunity – MCK Taguig, Cyber Sigma Building

Work schedule: Weekdays Night Shift schedule, Fixed Weekends Off

Responsibilities
  • Effectively review inpatient and/or outpatient medical necessity and authorization denials to determine and understand the validity of such denials in a timely manner -- Should conduct comprehensive reviews of the claim denial and account, to make determinations of what action to be taken to obtain reimbursement.
  • Utilize payer policies, MCG and InterQual criteria to determine if account meets criteria for appeal
  • Should write an appeal letter to payer using appropriate clinical indicators, citing Official Coding Guidelines, and documentation from within the patient's medical record
  • Perform all other necessary steps on the specified accounts per Clients SOP’s including documentation in the EMR, including appeal package creation
  • Manage the accounts until payment is received, the account is written-off, transferred to patient-liability, or other adjudication / movement within the system that is appropriate and agreed upon by both Parties
  • Reporting quality results, tracking and trending of educational opportunities of the coding and CDI specialists, responding to client subject matter needs, and providing educational support and training
Qualifications
  • PH Registered Nurse with experience in doing medical necessity appeals, lack of authorization appeals.(6 months needed)
  • Proficient in reading Explanation of Benefits (EOB) and investigating denial root causes.
  • Must be skilled in navigating various payer and provider portals.
  • Typing speed of at least 45 WPM.
  • Strong command of the English language, both spoken and written.
  • Willing to work night shifts to communicate with payers.
  • Familiarity with MCG and InterQual is a plus.
  • Must NOT hold a USRN license
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