Phrn

6 days ago

Taguig, National Capital Region, Philippines HRTX Full time ₱103,162 - ₱552,000 per year


Quality Auditor hiring Clinical Authorization Process.

Onsite, Night Shift, Mon-Friday

Qualifications

  • Must hold an active PHRN license (not a USRN license holder)
  • Relevant experience as a Quality Auditor in Clinical Services within a healthcare BPO environment; alternatively, 4 to 7 years of specialized experience in Clinical Authorization or Utilization Review is preferred
  • Strong familiarity with EPIC, MCG, or InterQual guidelines required
  • Demonstrated job stability, with a consistent employment history and minimal transitions

Job Description

I. Audit

  • Completing QA audits for their processes by following the QIP
  • Providing feedback to team members on all errors
  • Escalating any anomalies / trends / Compliance issues
  • Performing the actual production work to keep abreast of the latest updates and practical scenarios
  • Participating in client calls to capture process updates and monitoring compliance to the updates

II. Process

  • Contact insurance carriers to verify patients insurance eligibility, benefits, and requirements.
  • Request, track, and obtain pre-authorization from insurance carriers within time allotted for medical and services.
  • Review, request, follow up and secure authorizations for high dollar cost oncology chemotherapy drugs.
  • Demonstrate and apply knowledge of medical terminology, high proficiency of general medical office procedures including HIPAA regulations.
  • Assist with medical necessity documentation to expedite approvals and ensure that appropriate follow-up is performed.
  • Review denials and follow up with provider to obtain medically necessary information to submit an appeal of the denial.
  • Prioritize the incoming authorizations by level of urgency to the patient.
  • Manage correspondence with insurance companies, physicians, specialists, and patients as needed, including documenting in the EHR as appropriate.
  • Respond to clinical questions regarding payer medical policy guidelines

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