PHRN - Clinical Denials and Appeals

Work set up: Onsite Opportunity – MCK Taguig, Cyber Sigma Building

Work schedule :Weekdays Night Shift schedule, Fixed Weekends Off

• Effectively review inpatient and/or outpatient medical necessity and authorization denials to determine and understand the validity of such denials in a timely manner --Should conduct comprehensive reviews of the claim denial and account, to make determinations of what action to be taken to obtain reimbursement.
• Utilize payer policies, MCG and InterQual criteria to determine if account meets criteria for appeal
• Should write an appeal letter to payer using appropriate clinical indicators, citing Official Coding Guidelines, and documentation from within the patient's medical record
• Perform all other necessary steps on the specified accounts per Clients SOP’s including documentation in the EMR, including appeal package creation
• Manage the accounts until payment is received, the account is written-off, transferred to patient-liability, or other adjudication / movement within the system that is appropriate and agreed upon by both Parties
• Reporting quality results, tracking and trending of educational opportunities of the coding and CDI specialists, responding to client subject matter needs, and providing educational support and training

• PH Registered Nurse with experience in doing medical necessity appeals, lack of authorization appeals.(6 months needed)
• Proficient in reading Explanation of Benefits (EOB) and investigating denial root causes.
• Must be skilled in navigating various payer and provider portals.
• Typing speed of at least 45 WPM.
• Strong command of the English language, both spoken and written.
• Willing to work night shifts to communicate with payers.
• Familiarity with MCG and InterQual is a plus.
• Must NOT hold a USRN license