Reimbursement Clinical Case Manager

Job Title: Reimbursement Clinical Case Manager
Category: Healthcare/Medical
Main location: Cebu (onsite)
Work schedule: Shifting
Salary: PHP
Employment Type: Full Time
Target start date: February 14 2025
Headcount: 1

POSITION SUMMARY:

The Clinical Case Manager will be responsible for determining patient eligibility and benefits answering billing questions and obtaining authorizations and predeterminations. This role also involves researching and resolving inquiries related to payer authorizations and medical policy requirements.

Key responsibilities include processing insurance verification requests securing prior authorization
approvals and handling medical verifications of insurance policies coding billing and claims.
Additionally the Clinical Case Manager will review clinical documents to ensure they meet payer
medical guidelines ensuring compliance and optimizing approval rates. The role requires effective
communication with physician offices health plans and the Companys sales team. Collaboration with health plan personnel and physicians to gather necessary clinical information is essential. Adherence to all relevant policies procedures processes and systems is crucial to optimize reimbursement levels.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

Process clinical authorizations and insurance verification requests (IVRs) from the data intake team reviewing and correcting data entry errors and omissions.
Obtain benefit coverage levels and prior authorization requirements from health plans submit
necessary paperwork follow up on requests enter details into the database and submit for
predeterminations as needed.
Analyze and interpret collected data make coverage determinations notify providers of decisions and collaborate with sales and field reimbursement teams to ensure accurate information.
Respond to inquiries from physicians hospitals and outpatient facilities regarding billing and coding procedures.
Maintain open lines of communication while responding to inquiries from Field Reimbursement
Managers regarding errors faxbacks and IVR results.
Ensure clinical criteria meets payer requirements by obtaining necessary information from health
plans physicians and the reimbursement team.
Interact with health plan case managers medical directors and physicians to educate and influence reimbursement approval decisions handling calls related to medical documentation and clinical assessments.
Work with leadership to ensure timely reporting of changes in payor behaviors coverage or
reimbursement trends.
Follow HIPAA policies and procedures to ensure compliance

EDUCATION/EXPERIENCE:
25 years of experience in related field with 13 years of progressive responsible positions or
verifiable ability
Basic knowledge of medical coding including ICD10 CPT and HCPCS codes; AAPC certification a plus
Comprehensive understanding of Medicare Commercial and Medicaid health plans
Comprehensive understanding of medical management and health insurance concepts
Experience in insurance verification appeals negotiations and processing billing/claims processing data processing and software operations in the health care industry

PROBLEM SOLVING:

Performs a full range of standard professionallevel work which involves processing and
interpreting complex and less clearly defined issues. Identifies problems explores possible
solutions and takes appropriate actions to resolve them.
Demonstrates proficiency in data analysis techniques by addressing missing or incomplete
information and resolving inconsistencies and anomalies in complex research and data

DECISION MAKING/SCOPE OF AUTHORITY:
Nature of work requires increasing independence; receives guidance only on unusual complex
problems or issues.
Work review typically involves periodic review of output by supervisor and/or direct customers
of the process.

Qualify Candidates should send CV to indicating the subject.

Job Title: Reimbursement Clinical Case Manager
Category: Healthcare/Medical
Main location: Cebu (onsite)
Work schedule: Shifting
Salary: PHP
Employment Type: Full Time
Target start date: February 14 2025
Headcount: 1

POSITION SUMMARY:

The Clinical Case Manager will be responsible for determining patient eligibility and benefits answering billing questions and obtaining authorizations and predeterminations. This role also involves researching and resolving inquiries related to payer authorizations and medical policy requirements.

Key responsibilities include processing insurance verification requests securing prior authorization
approvals and handling medical verifications of insurance policies coding billing and claims.
Additionally the Clinical Case Manager will review clinical documents to ensure they meet payer
medical guidelines ensuring compliance and optimizing approval rates. The role requires effective
communication with physician offices health plans and the Companys sales team. Collaboration with health plan personnel and physicians to gather necessary clinical information is essential. Adherence to all relevant policies procedures processes and systems is crucial to optimize reimbursement levels.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

Process clinical authorizations and insurance verification requests (IVRs) from the data intake team reviewing and correcting data entry errors and omissions.
Obtain benefit coverage levels and prior authorization requirements from health plans submit
necessary paperwork follow up on requests enter details into the database and submit for
predeterminations as needed.
Analyze and interpret collected data make coverage determinations notify providers of decisions and collaborate with sales and field reimbursement teams to ensure accurate information.
Respond to inquiries from physicians hospitals and outpatient facilities regarding billing and coding procedures.
Maintain open lines of communication while responding to inquiries from Field Reimbursement
Managers regarding errors faxbacks and IVR results.
Ensure clinical criteria meets payer requirements by obtaining necessary information from health
plans physicians and the reimbursement team.
Interact with health plan case managers medical directors and physicians to educate and influence reimbursement approval decisions handling calls related to medical documentation and clinical assessments.
Work with leadership to ensure timely reporting of changes in payor behaviors coverage or
reimbursement trends.
Follow HIPAA policies and procedures to ensure compliance

EDUCATION/EXPERIENCE:
25 years of experience in related field with 13 years of progressive responsible positions or
verifiable ability
Basic knowledge of medical coding including ICD10 CPT and HCPCS codes; AAPC certification a plus
Comprehensive understanding of Medicare Commercial and Medicaid health plans
Comprehensive understanding of medical management and health insurance concepts
Experience in insurance verification appeals negotiations and processing billing/claims processing data processing and software operations in the health care industry

PROBLEM SOLVING:

Performs a full range of standard professionallevel work which involves processing and
interpreting complex and less clearly defined issues. Identifies problems explores possible
solutions and takes appropriate actions to resolve them.
Demonstrates proficiency in data analysis techniques by addressing missing or incomplete
information and resolving inconsistencies and anomalies in complex research and data

DECISION MAKING/SCOPE OF AUTHORITY:
Nature of work requires increasing independence; receives guidance only on unusual complex
problems or issues.
Work review typically involves periodic review of output by supervisor and/or direct customers
of the process.