PHRN QA

4 days ago

Taguig, National Capital Region, Philippines AGS health Full time ₱120,000 - ₱180,000 per year

Job Title: Quality Auditor - Clinical Authorization Specialist

Location: Robinsons Cyber Sigma Building, McKinley Taguig

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 (Surgery and Pharma)


• 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 patient's 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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