PHRN - Clinical Denials and Appeals

Recruitify_HR; Taguig; On-site; PHP 360,000 - 600,000; Full time

Job summary

A healthcare staffing agency is seeking a PH Registered Nurse with experience in medical necessity appeals for an onsite night shift role in Taguig. The candidate will review denials, write appeal letters, and manage accounts until resolution. Must possess strong English skills and the ability to navigate various payer portals. This role requires night shifts for communication with payers and does not permit USRN licenses.

Qualifications

• Must have at least 6 months of experience in medical necessity and lack of authorization appeals.
• Must be familiar with MCG and InterQual criteria.
• Must NOT hold a USRN license.
• Proficient in reading Explanation of Benefits (EOB) and denial investigation.

Responsibilities

• Review inpatient and outpatient medical necessity and authorization denials.
• Utilize payer policies and criteria to determine appeal eligibility.
• Write appeal letters citing appropriate documentation.
• Manage accounts until payment is received or written-off.
• Provide quality reporting and educational support.

Skills

Medical necessity appeals

Authorization appeals

Strong command of English

Typing speed of at least 45 WPM

Navigating payer and provider portals

Night shift

USRN license not required

Education

PH Registered Nurse

Job description

Overview

Work set up: Onsite Opportunity MCK Taguig, Cyber Sigma Building

Work schedule: Weekdays Night Shift schedule, Fixed Weekends Off

Responsibilities

• 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 SOPs 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
• PH Registered Nurse with experience in doing medical necessity appeals, lack of authorization appeals.
• 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

Qualifications

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