Clinical Appeals QA Specialist - PHRN

JOB SUMMARY:
Responsible for maintaining audits of accounts processed by the associate. Quality Audit Specialist (QA Specialist) ensures compliance with industry standards and client-specific guidelines. QA Specialist monitors, tracks, and trends audit findings to be shared with the management team (Operations, Training, and Quality). QA Specialist collaborates with the management team in providing actionable measures to maintain and/or improve the quality of the associate and the team.

RESPONSIBILITIES

- Participates in the design of quality monitoring formats and quality standards.
- Participates in meetings and training sessions with the management team (Training & Quality, Operation) and with the client that is relevant to quality initiatives and improvement.
- Able to compile and track the performance of the team and associate level.
- Performs quality audits and provides trends based on the data to the management team.
- Provides findings, recommendations, and action plans based on the quality audits to the management team (Operations, Training & Quality).
- Coordinates and facilitates calibration sessions for associates and management team (Operations, Training & Quality).
- Provides feedback and/or coaching sessions to associates accordingly.
- Prepares and analyzes internal and external quality reports to provide insights into quality improvement.
- Adhere to the individual MiraMed’s Compliance Guideline Policy and Procedure memos as distributed.
- Adheres to HIPAA privacy and security policies and practices.
- Other tasks/functions that may be assigned by the company as per business requirements (such as participating in doing the production and provide training to new hires during critical days); may change from time to time to reflect the changing requirement of your position and our business.

Qualifications:

- Minimum of 1-year experience in BPO healthcare, insurance, finance, medical, hospital accounts, or customer service-related field
- Must be an active Philippines Registered Nurse.
- Must have QA appeals background.
- With Revenue Cycle (healthcare business, financial or insurance) experience
- Knowledge of billing and insurance terminologies
- Knowledge of billing forms such as UB-04 and CMS-1500
- Must be able to maintain the strictest confidentiality.
- Able to review clinical denials in a timely manner and appropriately utilizing clinical criteria sets such as of InterQual® criteria (Acute, Procedures, etc.). If clinical review does not meet IQ criteria, other pertinent clinical facts are utilized to support the appeal. Pertinent clinical facts include, but are not limited to, documentation preventing a safe transfer/discharge or documentation of medically necessary services denied for no authorization.
- Able to write an effective and efficient appeal based on clinical documentation and payer-specific policies and client-specific instructions.
- Able to think critically and able to use clinical judgment in providing effective and well-supported appeals.
- Has analytical, problem-solving/decision-making skills