PHRN - Utilization Review / Clinical Authorization
- Taguig City, Metro Manila
- ₱50,000 per month
- Permanent
- Full-time
Schedule: Night Shift | Monday to Friday
Hiring Target Date: Preferably by July 21, 2025
Salary Range: Up to 50kQualificationsMust hold an active PHRN license (Not a USRN holder)
Prior experience as a Quality Auditor in a healthcare BPO clinical setting
Alternatively, 4 to 7 years of specialized experience in Clinical Authorization or Utilization Review
Strong knowledge of EPIC, MCG, or InterQual guidelines
Must have a stable work history with minimal employment transitionsKey ResponsibilitiesI. Quality Auditing
- Conduct audits in accordance with Quality Improvement Plans (QIP)
- Provide actionable feedback to team members and track corrections
- Escalate compliance concerns, trends, and anomalies to leadership
- Stay updated through production work and active participation in process updates
- Join client calls to ensure accurate capture of updates and compliance
- Verify patient insurance eligibility, benefits, and requirements with payers
- Request, track, and secure pre-authorizations for medical services and procedures
- Review and follow up on oncology chemotherapy drug authorizations
- Ensure HIPAA compliance and maintain proper documentation in EHR
- Handle medical necessity documentation and assist in denial appeals
- Prioritize cases based on urgency and patient impact
- Communicate with insurance companies, healthcare providers, and patients as needed
- Address clinical inquiries based on payer medical policy guidelines