Hiring PHRN – Voice Support

Job Responsibilities
• Clinical Review & Utilization Management
Evaluate medical records and conduct utilization reviews to ensure services provided are medically necessary and aligned with patient diagnoses and healthcare guidelines.

• Medical Claims Validation
Analyze and determine the eligibility and medical necessity of claims, coordinating with providers to ensure proper documentation and compliance with payer policies.

• Patient & Provider Communication
Serve as a liaison between patients, providers, and healthcare facilities to discuss diagnoses, treatment plans, and discharge processes, ensuring clarity and continuity of care.

• Pre-Authorization & Coverage Determination
Perform pre-service and retrospective clinical reviews using standardized criteria (e.g., MCG/IQ), ensuring proper benefit application and forwarding complex cases to medical directors when necessary.

• Regulatory Compliance & Documentation
Adhere to legal and regulatory standards (e.g., HIPAA, CMS) while accurately documenting assessments, findings, and outcomes to support quality assurance and care improvement initiatives.

Job Requirements:
• Active Philippine Registered Nurse (PHRN) License
Must hold a valid and active PHRN license.

• Clinical Experience
Minimum of 1 year hospital experience with direct patient care or employment as a Company/Clinic Nurse with verifiable Certificate of Employment (COE).

• Medical Knowledge & Analytical Skills
Strong understanding of clinical practices, diagnostic procedures, and treatment protocols. Ability to analyze medical records and assess claim eligibility based on medical necessity.

• Communication Proficiency
Excellent verbal and written communication skills in English; capable of clearly interacting with patients, providers, and internal teams.

• Technical and Regulatory Acumen
Familiarity with healthcare regulations and clinical guidelines (e.g., MCG, IQ, HIPAA). Ability to use medical management software and conduct detailed case reviews efficiently.