PHRN - Utilization Review / Clinical Authorization

We're Hiring: PHRN Quality Auditor Clinical Services

Location: Onsite, Mckinley, Taguig
Schedule: Night Shift | Monday to Friday
Hiring Target Date: Preferably by July 21, 2025
Salary Range: Up to 50k

Qualifications

Must hold an active PHRN license (Not a USRN holder)
Prior experience as a Quality Auditor in a healthcare BPO clinical setting
Alternatively, 4 to 7 years of specialized experience in Clinical Authorization or Utilization Review
Strong knowledge of EPIC, MCG, or InterQual guidelines
Must have a stable work history with minimal employment transitions

Key Responsibilities

I. Quality Auditing

• Conduct audits in accordance with Quality Improvement Plans (QIP)
• Provide actionable feedback to team members and track corrections
• Escalate compliance concerns, trends, and anomalies to leadership
• Stay updated through production work and active participation in process updates
• Join client calls to ensure accurate capture of updates and compliance

II. Clinical Process Management

• Verify patient insurance eligibility, benefits, and requirements with payers
• Request, track, and secure pre-authorizations for medical services and procedures
• Review and follow up on oncology chemotherapy drug authorizations
• Ensure HIPAA compliance and maintain proper documentation in EHR
• Handle medical necessity documentation and assist in denial appeals
• Prioritize cases based on urgency and patient impact
• Communicate with insurance companies, healthcare providers, and patients as needed
• Address clinical inquiries based on payer medical policy guidelines