Medical Revenue Cycle Specialist – Pediatric Private Duty Nursing

All Jobs > Medical Revenue Cycle Specialist – Pediatric Private Duty Nursing (PDN) | Philippines

Medical Revenue Cycle Specialist – Pediatric Private Duty Nursing (PDN) | Philippines
Fully Remote Remote - Philippines, PHL

Description

The Medical Revenue Cycle Specialist is responsible for managing insurance verification, authorization requests, Single Case Agreements (SCAs), and reauthorization processes for Pediatric Private Duty Nursing (PDN) patients. This role ensures that required documentation is complete, authorization requests are submitted and tracked appropriately, payer requirements are met, and approvals are secured and documented before services begin.

The specialist works closely with Sales and Intake, Clinical, Scheduling, Recruiting, Accounting, and Operations teams to support timely patient onboarding, continuity of care, accurate authorization records, and compliance with payer requirements.

Key Responsibilities

1. New Case Intake and Insurance Verification

• Review new patient referrals and ensure all required demographic, insurance, and clinical information is collected before initiating authorization requests.
• Verify patient eligibility, coverage effective dates, primary and secondary insurance, member out‑of‑pocket responsibilities, and out‑of‑network benefits.
• Perform insurance verification through the appropriate payer portals, including the NJ Medicaid Portal and Availity, or by contacting insurance carriers directly.
• Identify authorization and Single Case Agreement (SCA) requirements for each insurance plan.
• Obtain and document Care Manager contact information, including name, phone number, and email address.
• Verify discharge dates for hospitalized patients before proceeding with authorization requests.
• Follow coordination‑of‑benefits requirements for patients with both commercial insurance and NJ Medicaid coverage.

2. Authorization and Single Case Agreement (SCA) Management

• Collect and review required clinical documentation, including the Letter of Medical Necessity (LOMN), diagnosis information, clinical notes, available medical records, and physician orders or Form 485 when available.
• Coordinate with the Clinical team to ensure documentation supports the requested nursing hours, frequency, and duration of services.
• Prepare and submit complete authorization packets to insurance companies' Utilization Management (UM) departments.
• Record submission dates, reference numbers, requested services, and other relevant authorization details.
• Monitor authorization requests and follow up with insurance carriers to obtain determinations and address outstanding requirements.
• Determine whether an SCA is required and coordinate the process for finalizing agreements when applicable.
• Support the SCA process by coordinating reimbursement rate discussions and documenting approved rates and service parameters.
• Identify cases that may require a Gap Exception and coordinate with the appropriate parties when an in‑network pediatric home care provider is unavailable.
• Obtain and verify written authorization approvals, ensuring approved dates, hours, frequency, duration, and authorization numbers are accurately documented.
• Escalate delayed, incomplete, or denied authorization requests to the appropriate internal stakeholders.

3. Reauthorization and Authorization Expiration Tracking

• Maintain an accurate tracking system for authorization effective dates and expiration dates.
• Begin reauthorization preparation at least two weeks before the current authorization expires.
• Coordinate with the Clinical team to obtain the most recent two weeks of clinical notes, current physician orders or Form 485, nursing assessments, Plan of Care (POC), and updated LOMN when required.
• Reverify insurance eligibility, coordination of benefits, Care Manager information, and payer submission requirements.
• Review reauthorization packets for consistency across diagnosis, requested nursing hours, frequency, duration, and supporting documentation.
• Submit complete reauthorization requests before the current authorization expires.
• Monitor pending requests, follow up on outstanding items, and coordinate additional documentation, exception requests, or appeals as needed.
• Verify approved reauthorization details and ensure updated authorizations are entered into the appropriate systems before the new authorization period begins.

4. Appeals and Clinical Documentation Coordination

• Coordinate the collection of updated clinical documentation and medical necessity support for appeals and exception requests.
• Work with the Clinical team to obtain updated LOMNs and other supporting re