QUALITY AUDITOR, clinical servicesKMC MAG Solutions Inc

Functional overview . Provide health care utilization review services regarding admissions, observations, Discharge Wqs based on the payer types and review types. . Review admissions and service requests within assigned unit for prospective, concurrent, and retrospective medical necessity and/or compliance with reimbursement policy criteria. . Assist with issues related to coding, medical records/documentation, precertification, reimbursement and claim denials/appeals. . Notifies attending physician and other members of the health care team of inappropriate admissions, denials, end of authorized days, or other factors that have a reimbursement impact. . Consults with attending physician when documentation in the medical record does not support admission or continued stay and seeks to ensure completeness of all clinical documentation. . Functions as liaison between the Physician Advisor and the attending physician.. . Documents denial information in electronic medical record system including attempts at resolution/overturning of the denial. . Provides all payor communication to be scanned into the system for use in appeals. . Application of MCG and InterQual guidelines for each case review to determine the status. . Consults with medical and treatment staff regarding client diagnosis, medical justification, length of treatment, and case documentation. . Participates in utilization and peer review meetings and projects. Duties and responsibilities Identify and list down job responsibilities that are important and would comprise 80-90 percent of the work that should be done. Can be listed in order of process or importance. Minimum competencies Should list down skills, knowledge and/or behaviour. Can include areas of expertise. Minimum qualifications Indicate required educational background. Previous work experiences needed or preferred. Any technical skills required.
foundit

Taguig City, Metro Manila
Permanent
Full-time