Clinical Authorization Specialist

2 days ago

Taguig, National Capital Region, Philippines beBeeClinicalAuthorization Full time ₱30,000 - ₱45,000
About Our Role

We are seeking a skilled professional to join our team in the field of Utilization Review and Clinical Authorization.

Job Overview

This role is responsible for conducting audits in accordance with Quality Improvement Plans (QIP), providing actionable feedback, and tracking corrections. Additionally, this position involves verifying patient insurance eligibility, benefits, and requirements with payers, requesting, tracking, and securing pre-authorizations for medical services and procedures.

Key Responsibilities
  • Quality Auditing: Conduct audits in accordance with Quality Improvement Plans (QIP), provide actionable feedback, track corrections, escalate compliance concerns, trends, and anomalies to leadership, stay updated through production work and active participation in process updates, and 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, 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, and address clinical inquiries based on payer medical policy guidelines.
Requirements
  • 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
Benefits
  • Full-time employment
  • Healthcare provider environment
  • Technology and information industry

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