PHRN – Clinical Denials and Appeals

Gratitude Inc

1568 Views

19 hours ago

0-1 Year(s)

₱ 10 - ₱ 50K p.m

Manila (Taguig)

Job Description

Key Skills

PHRN lack of authorization appeals investigating denial root causes typing speed test Proficient in reading Explanation of Benefits (EOB)

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Job Description

Effectively review inpatient and/or outpatient medical necessity and authorisation denials to determine and understand the validity of such denials promptly

Should conduct comprehensive reviews of the claim denial and account to make determinations of what action to take to obtain reimbursement.

Utilise payer policies, MCG and InterQual criteria to determine if the account meets the criteria for appeal

Should write an appeal letter to the payer using appropriate clinical indicators, citing Official Coding Guidelines, and documentation from within the patient's medical record

Perform all other necessary steps on the specified accounts per Client SOP’s including documentation in the EMR, including appeal package creation.

Manage the accounts until payment is received, the account is written-off, transferred to patient liability, or other adjudication/movement within the system that is appropriate and agreed upon by both Parties

Reporting quality results, tracking and trending of educational opportunities of the coding and CDI specialists, responding to client subject matter needs, and providing educational support and training

Qualifications:

PH Registered Nurse with experience in doing medical necessity appeals, lack of authorisation appeals. (6 months needed)

Proficient in reading Explanation of Benefits (EOB) and investigating denial root causes.

Must be skilled in navigating various payer and provider portals.

Typing speed of at least 45 WPM.

Strong command of the English language, both spoken and written.

Willing to work night shifts to communicate with payers.

Familiarity with MCG and InterQual is a plus.

Must NOT hold a USRN license

Role

Nurse

Timings

Night Shift (Permanent)

Industry

Medical / Healthcare / Hospital

Work Mode

Work from office

Functional Area

Medical Professional / Healthcare Practitioner / Technician

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