Perform analysis on clinical documentation, evidenced-based criteria application outcome, physician documentation, physician advisor input and complete review of the medical record related to clinical denials. Assure appropriate action is taken within appeal time frames to address clinical denials. Collaborate with Patient Financial Services for continued appeal processes. Coordinate Clinical Denial appeal follow up.
- Formulates and submits appeals. Creates an effective appeal utilizing relevant and effective clinical documentation from the medical record; supported by current industry clinical guidelines, evidence-based medicine, community, and national medical management standards and protocols.
- Performs review of all claims denied for clinical-related attributions, including but not limited to: level of care, no authorization, medical necessity, non covered benefits and denied days.
- Work in Epic work queues to identify, analyze, and process denied claims towards an accurate adjudication expectation according to the contracts and federal regulations. Including, but not limited to:
- Calling insurance carriers
- Accessing insurance website
- Challenging poor adjudication from insurance carriers (via phone/web/mail), including;
- Reconsideration requests
- Reading and comprehending medical records
- Following workflow guidelines, as provided by the client, including:
- Mail must be sent back to the client for mailing in our facility
- Claim correction and utilization review considerations are to be routed through client protocols
- 1-3 years of Clinical RN experience
- 1-2 years of current experience with reimbursement methodologies
- Strong communication skills (verbal/written) and interpersonal skills
- Proficient in PC use, Microsoft applications
- Effectively organizes work priorities
- Demonstrates compliance with departmental safety and security policies and practices.
- Demonstrates critical thinking, analytical skills, and ability to resolve problems
- Demonstrated ability to handle multiple assignments and carry out work independently with minimal supervision
- Demonstrates responsibility for professional development.
- Location: Ortigas, Pasig
- Shift: Night Shift (Weekends Off)
- Salary: 40K to 65K monthly package (depending on the experience)
Please send your resume to firstname.lastname@example.org
Contact us: (02) 3491 – 7325
Or visit us in one of our Offices:
Ortigas Branch: 11/F Wynsum Corporate Plaza, #22 F. Ortigas Jr. Road Ortigas Center, Pasig City Philippines
Mandaluyong Branch: 20th Flr Robinsons Cybergate 3, Pioneer St., Mandaluyong
BGC Branch: Unit 1504 Ecotower Building, 32nd Street corner 9th Avenue Bonifacio Global City, Taguig City Philippines