PHRN - QA (Prior Authorization) ONSITE

Prioritize incoming authorization and referral requests according to queue urgency

Review patient's clinical and chart documentation related to the service submitted by the provider's office

Obtain and/or follow up on authorization and referral requests from the patient's payer/s through any of the following methods—depending on the payer's policy:

Perform outbound calls to payer's authorization department

Access payer's authorization online portal

Submit faxes to payer's authorization department

Respond to payer's clinical questions to be able to proceed with the authorization and referral requests

Obtain and/or follow up payer's peer-to-peer review requirements and send them back to provider's office for the actual initiation

Cater inbound calls from payers and perform necessary actions required for the task

Listen and review voicemail messages from payers then perform necessary actions required for the task

Monitor activities of Nurses to assess schedule adherence, accuracy, quality, productivity, timeliness and compliance with job requirements, policies and procedures. Report updates to management.

Provide basic on-the-job training for direct reports and serve as a resource to address questions related to the policies, processes and procedures.

Delivers required number of QA Monitors on a timely manner

Provide quality metric analysis on compliance scores

Participates in call calibration to understand and identify targets

Generates and trends daily/weekly/monthly QA related reports

Performs side-by-side sessions and provide real-time feedback

Skilled in pinpointing root cause/s for performance variance

Provide recommended intervention activities to address quality metric opportunities identified

Solid understanding of anatomy & physiology, including how body systems function and an understanding of disease processes

Comprehensive understanding of Medical Terminology

Prior experience in processing multispecialty authorizations including contact with payers

Experience in prior authorization process

Experience with general computer software (Internet, Word, Outlook, PDF required)

Proficiency to learn new software programs quickly

Excellent customer service skills: communicates clearly and effectively

Excellent verbal and written communication skills

Professional and effective interaction skills with co-workers, clients, providers, and vendors

Proven ability to work well individually and as a team member

Strong attention to detail

Ability to follow company and account-specific standard operating procedures and policies

Ability to adapt to constantly changing environment

Ability to prioritize and organize multiple tasks by remaining focused and quality-driven at all tasks at hand

Ability to remain organized with multiple interruptions

Ability to make decisions independently without bypassing any company and account-specific standard operating procedures and policies

Ability to comfortably receive constructive feedback

Graduate of Bachelor of Science in Nursing with active PH registered nurse license

1–2 years of experience of US healthcare authorization business

At least 2 years of experience in the BPO/Healthcare industry is an advantage

Bachelor's Degree in Nursing with active PH Registered Nurse license

Minimum 2 years of Quality Analyst experience in a US Healthcare account (Prior Authorization or Claims/Denial/Appeal)

Excellent Leadership & Interpersonal relationship

Strong Process Management & planning skills

Embrace change and think operationally to achieve business goals

Proven process improvement experience