PHRN Insurance Verification & Prior Authorization Nurse

AGS Health Philippines, Inc; Taguig; On-site; PHP 400,000 - 640,000; Full time

Job summary

AGS Health Philippines, Inc. seeks a skilled Utilization Review Specialist to verify insurance coverage, obtain pre-authorizations, and ensure medical necessity documentation complies with HIPAA regulations.

The role emphasizes accurate medical recordkeeping and timely coordination with insurers and care providers. Applicants should hold a PHRN license and have prior Utilization Review or Clinical Authorization experience, with responsibility for reviewing denials and supporting appeals while

Qualifications

• PHRN license holder.
• 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 required timeframes.
• Review and secure authorizations for high-cost oncology chemotherapy drugs.
• Maintain HIPAA-compliant medical office procedures and terminology knowledge.
• Assist with medical necessity documentation to expedite approvals and follow-up.
• Review denials and provide information for appeals.
• Prioritize authorization requests based on patient urgency.
• Manage correspondence with insurers, physicians, and patients; document in EHR as needed.
• Respond to clinical inquiries regarding payer medical policy guidelines.

Skills

PHRN license holder

Utilization Review experience

Clinical Authorization experience

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.