Clinical Authorization Nurse (PHRN)

AGS Health Philippines, Inc; Philippines; On-site; PHP 300,000 - 450,000; Full time

Job summary

AGS Health Philippines, Inc. is seeking a qualified Utilization Review professional in the Philippines to verify insurance eligibility, obtain pre-authorizations, and review high-cost oncology treatments.

The role requires a PHRN license and prior experience in utilization review or clinical authorization, with strong HIPAA knowledge and meticulous documentation in the EHR. Responsibilities include coordinating with carriers, clinicians, and patients; handling denials and appeals; and

Qualifications

• PHRN license holder required.
• Prior experience in Utilization Review and/or Clinical Authorization.

Responsibilities

• Contact insurance carriers to verify patients' insurance eligibility, benefits, and requirements.
• Request, track, and obtain pre-authorizations from insurance carriers within the required timeframe for medical services.
• Review, request, follow up on, and secure authorizations for high-cost oncology chemotherapy drugs.
• Demonstrate and apply knowledge of medical terminology and maintain a high level of proficiency in general medical office procedures, including HIPAA regulations.
• Assist with medical necessity documentation to expedite approvals and ensure appropriate follow-up is completed.
• Review denials and follow up with providers to obtain medically necessary information for submitting appeals.
• Prioritize incoming authorization requests based on the level of urgency for the patient.
• Manage correspondence with insurance companies, physicians, specialists, and patients as needed, including documenting information in the EHR when appropriate.
• Respond to clinical inquiries regarding payer medical policy guidelines.

Skills

Utilization Review

Clinical Authorization

Education

PHRN license holder

Job description

Qualifications

• PHRN license holder

• Prior experience in Utilization Review and/or Clinical Authorization

Responsibilities

• Contact insurance carriers to verify patients' insurance eligibility, benefits, and requirements.

• Request, track, and obtain pre-authorizations from insurance carriers within the required timeframe for medical services.

• Review, request, follow up on, and secure authorizations for high-cost oncology chemotherapy drugs.

• Demonstrate and apply knowledge of medical terminology and maintain a high level of proficiency in general medical office procedures, including HIPAA regulations.

• Assist with medical necessity documentation to expedite approvals and ensure appropriate follow-up is completed.

• Review denials and follow up with providers to obtain medically necessary information for submitting appeals.

• Prioritize incoming authorization requests based on the level of urgency for the patient.

• Manage correspondence with insurance companies, physicians, specialists, and patients as needed, including documenting information in the EHR when appropriate.

• Respond to clinical inquiries regarding payer medical policy guidelines.