Prior Authorization Quality Analyst
HR TechX Corp.
Date: 3 weeks ago
City: Taguig
Contract type: Full time
Qualifications
- Must hold an active PHRN license (not a USRN license holder)
- Relevant experience as a Quality Auditor in Clinical Services within a healthcare BPO environment; alternatively, 4 to 7 years of specialized experience in Clinical Authorization or Utilization Review is preferred
- Strong familiarity with EPIC, MCG, or InterQual guidelines required
- Demonstrated job stability, with a consistent employment history and minimal transitions
- Audit
- Completing QA audits for their processes by following the QIP
- Providing feedback to team members on all errors
- Escalating any anomalies / trends / Compliance issues
- Performing the actual production work to keep abreast of the latest updates and practical scenarios
- Participating in client calls to capture process updates and monitoring compliance to the updates
- Process
- Contact insurance carriers to verify patients 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
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