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Prior Authorization Quality Analyst
HRTXTaguig, Metro Manila, Philippines30+ days ago
Job descriptionAudit 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
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
Job Description
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Quality Analyst • Taguig, Metro Manila, Philippines
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