USRN w/ UR Denials + Interqual Experience

15 hours ago

Manila, National Capital Region, Philippines Omega Healthcare Management Services Inc. Full time ₱900,000 - ₱1,200,000 per year

Duties & Responsibilities

Work post discharge, prebill accounts efficiently and effectively on a daily basis to resolve accounts with "no auth numbers, ALOS vs. authorized days or other discrepancies

  • Evaluates clinical documentation on multiple patient accounts and escalates issues through the established channels
  • Perform accurate and timely documentation of all review activities based on policy and procedure
  • Demonstrates a working knowledge of managed care agreements based on available resources which may include and not be limited to payer UM Manual, policy and procedure, facility contract information. Escalates variations timely.
  • Work assigned accounts in eRequest to resolve outstanding issues
  • Report insurance denial trends identified during daily operational assignments
  • Contact facilities, physicians' offices and/or insurance companies to resolve denials/appeals if needed
  • Demonstrates knowledge of regulatory requirements, Ethics and Compliance policies, and quality initiatives; monitors self‐compliance and implements process changes to ensure compliance to such regulations and quality initiatives.
  • Assess CPT code(s) for outpatient accounts that require authorization when accounts have not been coded
  • Seeks assistance from immediate supervisor when in situations which are unclear or ambiguous
  • Communicates effectively and professionally with physicians, hospital staff, and outside agencies
  • Adhere to time and attendance policies
  • Adhere to all policies and procedures, including,  phone and internet usage, break utilization, etc.
  • Participate in education and training as needed
  • Establish and maintain relationships with all customers
  • Seeks assistance from immediate supervisor when in situations which are unclear or ambiguous
  • Adheres to established policy and procedure and standards of care; escalates issues through the established Chain of Command timely
  • Demonstrates commitment to teamwork and cooperation
  • Practice and adhere to the "Code of Conduct" philosophy and "Mission and Value Statement"

Qualifications:

  • Total of 2-5 years of experience in the US BPO/Healthcare industry
  • Bachelor's degree in nursing with active US license of any state
  • Minimum 1-2 years of experience in a US Healthcare account (Utilization Management or Clinical Denial and Appeal or InterQual is required)
  • Embrace change and think operationally to achieve business goals
  • Proven process improvement experience

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