Medical Revenue Cycle Specialist – Pediatric Private Duty Nursing

This is a fully remote position, open to applicants in Philippines.

📋 Description

• Assess new patient referrals and gather necessary demographic, insurance, and clinical details.

• Confirm insurance eligibility, coverage, benefits, coordination of benefits, and authorization/SCA requirements.

• Acquire and document Care Manager contact information and validate discharge dates.

• Collect and review clinical documentation, which includes LOMNs, diagnoses, clinical notes, medical records, physician orders, and Form 485.

• Prepare and submit authorization and reauthorization packets to the Utilization Management departments of insurance companies.

• Log submission dates, reference numbers, requested services, and authorization specifics.

• Monitor requests, follow up with payers, address outstanding requirements, and document decisions.

• Coordinate Single Case Agreements, reimbursement rate discussions, Gap Exceptions, appeals, and requests for exceptions.

• Track the effective and expiration dates of authorizations and begin reauthorization preparation at least two weeks prior to expiration.

• Maintain patient authorization records and establish applicable cases in AlayaCare and HHAeX.

• Communicate authorization specifics and approved hours to Scheduling and coordinate schedules with authorized service periods.

• Oversee compliance requirements, including nurse credentialing, EVV, authorized hours, and Care Manager approvals.

• Assist with dashboard reviews, exception resolution, pre-billing issue escalation, and patient status communications.

• Maintain trackers, reminders, follow-up logs, and case status records.

• Provide status updates, identify process challenges, and suggest enhancements.

• Escalate clinical support requests to licensed nurses and refrain from making independent clinical determinations.

⛳️ Requirements

• Experience in medical billing, healthcare administration, insurance verification, medical revenue cycle management, or prior authorization.

• Knowledge of health insurance eligibility, benefits verification, authorization requirements, and payer follow-up processes.

• Excellent organizational skills and the ability to manage multiple patient cases and authorization deadlines concurrently.

• Strong written and verbal communication abilities.

• High attention to detail when reviewing clinical documentation, authorization approvals, and patient records.

• Capability to track pending requests, proactively follow up, and escalate cases needing timely resolution.

• Proficiency in maintaining spreadsheets, trackers, and electronic patient records.

• Ability to adhere to established procedures, maintain precise documentation, and safeguard confidential patient information.

• Preferred: Experience in supporting pediatric home health or Private Duty Nursing (PDN).

• Preferred: Familiarity with NJ Medicaid and Medicaid Managed Care Organizations.

• Preferred: Experience using Availity, the NJ Medicaid Portal, AlayaCare, or HHAeX.

• Preferred: Understanding of Letters of Medical Necessity, Form 485, Plans of Care, Single Case Agreements, and reauthorization workflows.

🏝️ Benefits

• Fully remote work.

• Work-from-Home PLUS model.

• Positive, encouraging, and performance-driven culture.

• Opportunities to build rewarding, long-term careers.

• Tremendous opportunities for growth.