PHRN - Utilization Review / Clinical Authorization
3 weeks ago
We are hiring for the PHRN - Utilization Review / Clinical Authorization role at HR TechX Corp. Location: Onsite, Mckinley, Taguig. Schedule: Night Shift | Monday to Friday. Hiring Target Date: Preferably by July 21, 2025. Salary Range: Up to 50k.
Qualifications- Active PHRN license (Not a USRN)
- 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
- Stable work history with minimal employment transitions
- 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.
- 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.
- Not Applicable
- Full-time
- Health Care Provider
- Technology, Information and Internet
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