Job Description

Duties and Responsibilities:

• Conduct Non-Clinical Research to Support Determinations
• Determine that the case is assigned to the appropriate team and health plan for review (e.g., Medicare, Medicaid, Commercial, Dual Special Needs Plan)
• Validate that cases/requests for services require additional research
• Prioritize cases based on appropriate criteria (e.g., date of service, urgent, expedited)
• Ensure compliance with applicable federal/state requirements and mandates (e.g., turnaround times, medical necessity)

Review Existing Clinical Documentation * Review/interpret clinical/medical records submitted from provider (e.g., office records, test results, prior operative reports)

• Identify missing information from clinical/medical documentation, and request additional medical or clinical documentation as needed (e.g., LOI process, phone/fax)
• Review and validate diagnostic/procedure/service codes to ensure their relevance and accuracy, as applicable (e.g., Prior Authorization List (PNL/EPAL), state grid, LCDs, NCDs)
• Identify and validate usage of non-standard codes, as necessary (e.g., generic codes)
• Apply understanding of medical terminology and disease processes to interpret medical/clinical records
• Make determinations per relevant protocols, as appropriate (e.g., approval, denial process, conduct further clinical or non-clinical research)
• Review care coordinator assessments and clinical notes, as appropriate
• Make Final Determinations Based on Clinical and Departmental Guidelines
• Demonstrate understanding of business implications of clinical decisions to drive high quality of care
• Understand and adhere to applicable legal/regulatory requirements (e.g., federal/state requirements, HIPAA, CMS, NCQA/URAC accreditation)
• Ask critical questions to ensure member- and customer-centric approach to work
• Identify and consider appropriate options to mitigate issues related to quality, safety or risk, and escalate to ensure optimal outcomes, as needed
• Utilize evidence-based guidelines (e.g., medical necessity guidelines, practice standards, industry standards, best practices, and contractual requirements) to make clinical decisions, improve clinical outcomes and achieve business results
• Identify and implement innovative approaches to the practice of nursing, in order to achieve or enhance quality outcomes
• Use appropriate business metrics to optimize decisions and clinical outcomes
• Prioritize work based on business algorithms and established work processes (e.g., assessments, case/claim loads, previous hospitalizations, acuity, morbidity rates, quality of care follow up)
• Achieve and Maintain Established Productivity and Quality Goals
• Meet/exceed established productivity goals
• Adhere to relevant quality audit standards in performing reviews, making determinations and documenting recommendations
• Manage/prioritize workload and adjust priorities to meet quality and productivity goals80% Non-voice, 20% Voice (Outbound)

Requirements:

• USRN (Mainland) with atleast 1 year hospital experience
• With no hospital experience, we can accept candidates with BPO experience instead for atleast 1 year

Can accept expired license; Northern Marianas Island State License is also acceptedJob Type: Full-timeSalary: Php34,000.00 - Php44,000.00 per monthSchedule:

• Shift system