PHRN – Clinical Authorization

Go-Get Data Consultancy; Taguig; On-site; PHP 502,200 - 558,000; Full time

Job summary

A healthcare consulting firm in Taguig is looking for a PHRN – Clinical Authorization specialist. This role involves verifying insurance eligibility, managing authorizations for medical services, and documentation of medical necessity. Candidates should have a BS Nursing degree and at least 6 months of relevant experience. This opportunity is onsite with a night shift schedule and a competitive salary package.

Qualifications

• Active PHRN license preferred but not required.
• At least 6 months of experience in Clinical or Prior Authorization.
• Familiarity with medical necessity guidelines or criteria.

Responsibilities

• Contact insurance carriers to verify patient’s insurance eligibility.
• Request and track pre-authorization from insurance carriers.
• Review and secure authorizations for high-cost oncology drugs.

Skills

Verification of patient’s insurance eligibility

Pre-authorization processes

Medical necessity documentation

Knowledge of medical terminology

High proficiency in general medical office procedures

Education

BS Nursing degree

Tools

EPIC or any Electronic Health Record

Job description

Overview

• Job title: PHRN – Clinical Authorization
• Work set up: Onsite Opportunity – MCK Taguig, Cyber Sigma Building
• Work schedule: Weekdays Night Shift schedule, Fixed Weekends Off
• Salary: 45K to 50K package if licensed PHRN, salary for approval if non-licensed

Responsibilities

• 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

Qualifications

• Active PHRN license preferred but not required, as long as the candidate is a BS Nursing graduate
• Must not hold a USRN license
• At least 6 months of experience in Clinical or Prior Authorization, with familiarity in medical necessity guidelines or criteria
• At least 6 months of bedside nursing experience preferred but not required
• Knowledge in EPIC or any Electronic Health Record preferred
• Must be amenable to start immediately, onboarding will start on Wednesday, April 30