Utilization Review Nurse | Onsite, Night shift

MicroSourcing; Taguig; On-site; PHP 680,760 - 837,000; Full time

Job summary

MicroSourcing in Taguig, Metro Manila, Philippines is seeking a Utilization Review Nurse for on-site, full-time night-shift work to manage denials and appeals for payors in the US. You will review clinical documentation, perform medical necessity reviews, and prepare compelling appeals with attention to payer policies and contract language.

The role requires 3-5 years acute care experience (including ICU), a BSN, and active RN licensure (PHRN/USRN).

Qualifications

• At least 1 year of clinical appeals writing experience.
• 3-5 years acute care clinical experience in a hospital setting (Med/Surg) and 2-3 years ICU experience.
• Bachelor of Science in Nursing and active RN licensure (PHRN or USRN).
• Proficiency with InterQual/MCG guidelines and U.S. government programs.
• Experience with EMR systems (Epic/Cerner/Meditech) and MS Office.
• Excellent English communication skills (CEFR B2) in speaking and writing.

Responsibilities

• Review denied claims and manage the appeals process in a timely manner.
• Submit retro-authorizations as required by payors.
• Prepare clinical documentation for appeals and support with medical necessity reviews.
• Write and submit compelling written appeals based on documentation and payer policies.
• Document actions and track denials and appeals through final outcomes.
• Collaborate with teams to resolve payer discrepancies and improve A/R.
• Stay informed on payer guidelines and policy reforms.

Skills

Clinical Appeals

Acute care experience

InterQual/MCG knowledge

English communication

EMR proficiency

Education

Bachelor of Science in Nursing

Registered Nurse license (PHRN/USRN)

Tools

Epic

Cerner

Meditech

Microsoft Office

Job description

Utilization Review Nurse

• Taguig, Metro Manila, Philippines
• Full-Time
• On-Site
• Night shift
• 61,000-75,000 PHP / Month

Your Role

The Clinical Denials and Appeals Nurse Specialist (IP & OP) is responsible for reviewing the claims denied and carrying out the appeals process appropriately and in a timely manner. This individual identifies and works denials, responding to the denial reason and resubmitting any information needed to the payor. The Clinical Denials and Appeals Specialist should be knowledgeable of U.S. state/federal laws that relate to payor contracts and to the appeals process. This role requires frequent and effective communication via phone, email, and instant messaging with the various engagement teams. Strong oral and written communication skills, analytical skills, ability to work independently, and be self-motivated are required.

Denials and Appeals Management

• Work denials and appeals timely, evaluating the denial reason including information from the payor and payor policies, reviewing clinical documentation, assessing options and completing next steps
• Submit retro-authorizations in accordance with payor requirements in response to authorization denials
• Conduct medical necessity reviews, based on denial root cause, and prepare any required clinical documentation summaries to accompany appeals
• Write and submit written appeals that include compelling arguments based on clinical documentation, third-party payer medical policies, and contract language. Appeals are submitted timely and tracked through final outcome
• Document all actions taken and follow-up timely as needed related to resolving denials and appeals with third-party payers in a timely manner
• Track the status and progress of denials and appeals
• Completes relevant research to assist with completing the appeals process and to stay informed on best practices and policy reforms
• Executes internal and external correspondence accurately, clearly, concisely, and professionally while following organizational regulations
• Effectively handles all communications, including telephone, electronic, and paper correspondence from payers and departments within the business office

Tracking, Reporting, and Trends

• Maintain data on the types of claims denied and the root causes of denials
• Identify denial patterns and elevate to management as appropriate with sufficient information for further follow-up and root cause resolution
• Collaborate with management to recommend process changes to address the root cause of denials and overall improvement to reduce A/R
• Prepare, maintain, assist with, and submit reports as required

Compliance and Continuous Improvement

• Collaborate with team members to continually improve services, and engage in process and quality improvement activities
• Identify system improvement opportunities and contribute to the testing of system modifications
• Conduct relevant research to assist with completing the appeals process and stay informed on best practices and policy reforms
• Comply with state and federal regulations, accreditation/compliance requirements, and Huron’s policies, including those regarding fraud and abuse, confidentiality, and HIPAA
• Maintain a thorough understanding of federal and state regulations, as well as specific payer requirements and explanations of benefits, to identify and report billing compliance issues and payer discrepancies
• Participate in ongoing professional development to enhance job knowledge and performance
• Report all identified compliance risks to appropriate leadership

What You Need (Non-negotiables)

• Clinical Appeals Experience: At least 1 year of clinical appeal writing experience
• Clinical Experience: Minimum 3-5 years acute care clinical experience in a hospital setting (Med/Surg, or similar preferred); 2-3 years of ICU experience
• Education: Bachelor of Science in Nursing
• Licensure: Must be a Registered Nurse with an active PHRN or USRN license
• RCM Knowledge: Proficiency in using InterQual or MCG clinical guidelines; Broad Knowledge of U.S. Government Programs and Insurance Regulations
• Software Knowledge: Proficiency with hospital-based electronic medical records (EMR) such as Epic, Cerner, or Meditech
• Excellent verbal and written English communication skills and customer service skills (CEFR level at least B2 for both verbal and written)

Preferred Skills/expertise

• Education: Master’s degree or credential in business, healthcare, or related field preferred
• Credential/Certification: Case management or clinical appeals or clinical denials certification (ACMA) preferred
• Software Knowledge: Proficiency in using computer programs for tracking denials and appeals; Proficiency with Microsoft Office suite (Excel, Word, PowerPoint, Outlook, SharePoint)

Soft Skills

• Ability to pay close attention to details; strong follow-up and follow-through skills
• Regularly makes complex decisions within the scope of the position, and is comfortable working independently
• Requires independent judgment, discretion and decision-making abilities
• Demonstrates teamwork and integrity in all work-related activities
• Ability to interact with internal and external customers in a professional manner
• Strong analytical and critical thinking skills
• Experience in a matrixed environment
• Excellent written and verbal communication skills

Terms & conditions apply