PHRN / BPO Clinical Denials and Appeals

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

Job title: PHRN – Clinical Denials and Appeals
Work set up: Onsite Opportunity – Taguig City
Work schedule :Weekdays Night Shift schedule, Fixed Weekends Off
Salary: 45K to 50K salary package
One day hiring process

Job Description

-Effectively review inpatient and/or outpatient medical necessity and authorization denials to determine and understand the validity of such denials in a timely manner --Should conduct comprehensive reviews of the claim denial and account, to make determinations of what action to be taken to obtain reimbursement.
-Utilize payer policies, MCG and InterQual criteria to determine if account meets criteria for appeal
-Should write an appeal letter to 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 Clients 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 authorization 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
-Can start ASAP