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Job Summary: The Clinical Appeals Specialist (PHRN) is Responsible for the Review, Processing, and Resolution of Appeal(s) Case(s) in Compliance with NCQA and if Applicable, CMS Regulatory Standard(s) and Client Specific Guideline(s). You will Ensure Timely and Clinically Sound Appeal Determination(s), Upholding Member Right(s) and Health Plan Obligation(s) Under Commercial and CMS Regulation(s). You will also Support Case Documentation, Member and Provider Communication(s), and Contribute to the Quality and Compliance Target(s) of the Payor Program.
Essential Duties and Responsibilities:
- Review and Assess Appeal(s) Case(s) Submitted by our Member(s), Provider(s), and Authorized Representative(s) for Medicare Part C Service(s), Evaluate the Clinical Appropriateness of Initial Determination(s) Based on their Medical Necessity, Benefit Coverage(s), and Guideline(s) Determined and Implemented By CMS
- Document Appeal Decision(s) Clearly, Accurately, and in Compliance with CMS Requirement(s) and Client Specific Protocol(s), Ensure Timely Processing of Appeal Case(s) within the Regulatory Turnaround Time(s) Set by the CMS, Collaborate with Medical Director(s), Case Reviewer(s), Including Internal Department(s) to Gather the Required Clinical Information for Appeal Resolution
- Draft Clear as well as Compliant Member and/or Provider Correspondence Letter(s) Based on Appeal Outcome(s), Support the Appeal(s) Quality Program by Participating in Self-Audit(s) and Implementing Feedback for Continuous Improvement, Uphold High Level(s) of Confidentiality, Data Privacy, as well as HIPAA Compliance Standard(s), Escalate Complex or High-Risk Case(s) to Medical Director(s) or Appeals Leadership as Required, Participate in Training, Calibration, and Performance Discussion(s) to Maintain Clinical and Regulatory Knowledge
Minimum Hiring Qualifications:
- Active Philippine Registered Nurse (PHRN) with License Required - 1 Year(s) Minimum of Clinical Nursing Experience (Hospital, Clinic, or Managed Care Setting) with 6 Month(s) Minimum of Clinical Process Outsourcing Experience and Background Handling Clinical Role(s) Focusing on Clinical Appeals and Utilization Management and Other Related Function(s)
- Strong Clinical Knowledge Particularly in Medical Necessity Review and Interpretation of Clinical Documentation(s), With Good Knowledge and Understanding of the Different Healthcare Insurance Process(es), Appeals, Grievances, and Utilization Management is Preferred
- Demonstrates Excellent Verbal and Written Communication Skills, Strong Attention to Detail and Case Documentation Practice(s), Able to Manage Multiple Case(s) while Meeting Regulatory Turnaround Time(s) Under Pressure, Proficient in Basic Microsoft Office Application(s) such as Word, Excel, and Outlook, Willing to Work on Flexible Work Schedule(s) Including US Hour(s) and Holiday(s)
- Preferred Qualification(s): Experience Handling Medicare Part C or US-Based Appeals Case(s), Familiarity with CMS Guideline(s), NCQA Standard(s) and/or URAC Regulation(s), Experience in Using Appeals Management Platform(s) (VAM and Salesforce Health Cloud)
Get Hired and Enjoy the Following:
- Interact/Collaborate and Learn from Industry Experts
- Multiple Opportunities for Learning and Development
- Enjoy a Fun - and Competitive Working Environment
Work Location: Tera Tower, Bridgetowne, Quezon City
