US Registered Nurse ( UMR InterQual | Cebu (On Site)

Duties & Responsibilities

Work post discharge, prebill accounts efficiently and effectively on a daily basis to resolve accounts with “no auth numbers, ALOS vs. authorized days or other discrepancies

 Evaluates clinical documentation on multiple patient accounts and escalates issues through the established channels

 Perform accurate and timely documentation of all review activities based on policy and procedure

 Demonstrates a working knowledge of managed care agreements based on available resources which may include and not be limited to payer UM Manual, policy and procedure, facility contract information. Escalates variations timely.

 Work assigned accounts in eRequest to resolve outstanding issues

 Report insurance denial trends identified during daily operational assignments

 Contact facilities, physicians’ offices and/or insurance companies to resolve denials/appeals if needed

 Demonstrates knowledge of regulatory requirements, Ethics and Compliance policies, and quality initiatives; monitors self‐compliance and implements process changes to ensure compliance to such regulations and quality initiatives.

 Assess CPT code(s) for outpatient accounts that require authorization when accounts have not been coded

 Seeks assistance from immediate supervisor when in situations which are unclear or ambiguous

 Communicates effectively and professionally with physicians, hospital staff, and outside agencies

 Adhere to time and attendance policies

 Adhere to all policies and procedures, including, phone and internet usage, break utilization, etc.

 Participate in education and training as needed

 Establish and maintain relationships with all customers

 Seeks assistance from immediate supervisor when in situations which are unclear or ambiguous

 Adheres to established policy and procedure and standards of care; escalates issues through the established Chain of Command timely

 Demonstrates commitment to teamwork and cooperation

 Practice and adhere to the “Code of Conduct” philosophy and “Mission and Value Statement”

Qualifications:

· Total of 2-5 years of experience in the US BPO/Healthcare industry

· Bachelor's degree in Nursing with active US license of any state

· Minimum 1-2 years of experience in a US Healthcare account (Utilization Management or Clinical Denial and Appeal is required)

· Embrace change and think operationally to achieve business goals

· Proven process improvement experience