BPO Medical Records Specialist

Req ID: 379928 

We are currently seeking a BPO Medical Records Specialist to join our team in Manila, Quezon (PH-QUE), Philippines (PH).

Roles and Responsibilities:
• Provides guidance on preparing case reviews for Medical Directors by researching the appeal, reviewing applicable criteria, and analyzing the basis for the appeal. 
• Prepares case reviews for Medical Directors by researching the appeal, reviewing applicable criteria, and analyzing the basis for the appeal. 
• Ensures timely review, accurate processing, and response to appeal in accordance with State, Federal and NCQA standards.
• May also perform clinical reviews. Review claim appeal for reconsideration and recommend approvals/denials based on determination level or prepare for medical review presentation.
• Communicates with providers, facilities and other departments regarding appeal requests. 
• Generates appropriate appeals resolution communication and rep...