PHRN - Utilization Review / Clinical Authorization

HRTX; Taguig; On-site; PHP 507,780 - 608,220; Full time

Job summary

A healthcare organization in Taguig is seeking a Quality Auditor for Clinical Services. The role requires an active PHRN license and previous experience in a healthcare BPO clinical setting. Responsibilities include conducting audits, verifying insurance eligibility, and ensuring compliance. The position offers a salary of up to 50k and operates on a night shift schedule from Monday to Friday.

Qualifications

• Must have prior experience in a healthcare BPO clinical setting as a Quality Auditor.
• Should have 4 to 7 years of specialized experience in Clinical Authorization or Utilization Review.
• Stable work history with minimal employment transitions is required.

Responsibilities

• Conduct audits according to Quality Improvement Plans.
• Verify patient insurance eligibility and track pre-authorizations.
• Ensure HIPAA compliance and maintain documentation.

Skills

PHRN license

Quality Auditor experience

Clinical Authorization knowledge

EPIC knowledge

MCG guidelines understanding

InterQual guidelines knowledge

Strong communication

Education

Active PHRN license

Tools

EHR systems

Job description

About the job PHRN - Utilization Review / Clinical Authorization

We're Hiring: PHRN Quality Auditor Clinical Services

Location: Onsite, Mckinley, Taguig
Schedule: Night Shift | Monday to Friday
Hiring Target Date: Preferably by July 21, 2025
Salary Range: Up to 50k

Qualifications

Must hold an active PHRN license (Not a USRN holder)
Prior experience as a Quality Auditor in a healthcare BPO clinical setting
Alternatively, 4 to 7 years of specialized experience in Clinical Authorization or Utilization Review
Strong knowledge of EPIC, MCG, or InterQual guidelines
Must have a stable work history with minimal employment transitions

Key Responsibilities

I. Quality Auditing

• Conduct audits in accordance with Quality Improvement Plans (QIP)
• Provide actionable feedback to team members and track corrections
• Escalate compliance concerns, trends, and anomalies to leadership
• Stay updated through production work and active participation in process updates
• Join client calls to ensure accurate capture of updates and compliance

II. Clinical Process Management

• Verify patient insurance eligibility, benefits, and requirements with payers
• Request, track, and secure pre-authorizations for medical services and procedures
• Review and follow up on oncology chemotherapy drug authorizations
• Ensure HIPAA compliance and maintain proper documentation in EHR
• Handle medical necessity documentation and assist in denial appeals
• Prioritize cases based on urgency and patient impact
• Communicate with insurance companies, healthcare providers, and patients as needed
• Address clinical inquiries based on payer medical policy guidelines