Access Healthcare is looking for a Utilization and Clinical Denials Nurse to join our growing clinical account. The ideal candidate is a Licensed Philippines Nurse with at least two (2) years of hospital bedside experience and a strong understanding of utilization review, clinical documentation, and denial management in a BPO set-up. This role involves reviewing medical cases, ensuring compliance with payer requirements, and assisting in the appeals process for denied claims.
Key Responsibilities:
- Conduct utilization reviews to assess medical necessity, appropriateness, and efficiency of healthcare services.
- Analyze clinical denials and collaborate with internal teams to determine appeal strategies.
- Review medical records and ensure compliance with insurance policies and industry guidelines.
- Assist in preparing clinical appeals and reconsideration letters for denied claims.
- Provide medical rationale and justifications based on clinical evidence and payer guidelines.
- Communicate with insurance providers, physicians, and other healthcare professionals regarding authorization approvals or denials.
- Stay updated on healthcare policies, medical guidelines, and payer requirements to optimize claims processing.
- Ensure compliance with HIPAA regulations, data privacy laws, and company protocols.
Qualifications:
- Must be a Licensed Philippines Nurse (PH RN).
- At least two (2) year of hospital bedside experience (ICU, ER, Med-Surgery, or similar preferred).
- Experience in utilization review, clinical denials management, or medical claims processing is a must.
- Strong understanding of insurance policies, medical necessity criteria, and appeal processes.
- Excellent critical thinking, analytical, and problem-solving skills.
- Effective written and verbal communication skills.
- Proficiency in medical terminology, coding (ICD-10, CPT), and healthcare documentation is a plus.
- Ability to work in a fast-paced BPO environment with shifting schedules.
Job Type: Full-time
Pay: Php35,000.00 - Php40,000.00 per month
Benefits:
- Additional leave
- Health insurance
- Paid training
Schedule:
- 8 hour shift
- Evening shift
- Night shift
Supplemental Pay:
- 13th month salary
License/Certification:
- PRC ID (Required)
Willingness to travel:
- 100% (Required)
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