The Clinical Appeals Nurse (Clinical Claims Auditor) will be responsible for reviewing medical records to determine the medical appropriateness in a variety of care settings for clinical services rendered to beneficiaries of various health plans, including Commercial and Government Clients.
Your future duties and responsibilities:- In-charge with rendering independent, appropriate, well-supported, and thoroughly-documented decisions which may result in identification of improper payments on paid claims on behalf of the Client from various Providers of clinical services, including but not limited to acute care, outpatient and other provider types and care settings.
- Conducts inpatient and outpatient claim audits to determine medical necessity/reasonable and necessary services, validation of prior authorization, clinical validation, medical service charge audit, or other audit types as required, thereby recovering improper payments when it is determined through the audit process that the medical record does not support the services billed.
- Develops rationale for the audit decision based on the provider's submitted information, citing appropriate review guidelines, applicable regulations and/or internal review guidelines, and enters clearly documented information in the system. Follows the designated procedure for referral to a Physician Advisor if required by Client contract.
- For Clinical Validation audits, documents specified coding issues in conjunction with the DRG Validation Team as assigned.
- Complies with department standards regarding productivity and audit quality.
- Provides support, feedback, and guidance to the Auditor. Audit performance review, inter-rater reliability (IRR) and performance measurement (PM) are performed through a well-defined review and quality management program.
• Active registered nurse (Licensed PH RN and US RN)
• Bachelor's degree holder in BS Nursing
• Minimum 3 years experience in Clinical Appeals / Clinical Claims Auditor in a Clinical Process Outsourcing (CPO) industry
• Experience in ICU, CCU, and NICU bedside nursing experience in an overseas setting
• Good writing and communication skills - a well-written CV/resume is required for the role
• Critical decision making related to process/systems of ICU/CCU/NICU experience
• Working knowledge of computer functions, artificial intelligence tools, Microsoft Office (Outlook, Word, Excel) applications, and Windows operating systems is required in order to manage audit processes
• Amenable to work on a midshift schedule and hybrid working arrangement in Mckinley, Taguig
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