XTN-6EBA438 | QUALITY AUDITOR - CLINICAL AUTHORIZATION

AGS Health, LLC (AGS) is a technology-enabled Revenue Cycle Management ("RCM") company that provides financial clearance, financial management, and clinical coding solutions and services to healthcare providers and vendors across the US. AGS Health has 10,200 employees across multiple offices in India and the US. The company generates annualized revenues of over $US 100 million. The CEO and the company have ambitions to transform from a traditional healthcare services company to an integrated technology and services organization that serves an expanded set of customer segments and offers a more diverse set of products and services.

• Excellent Company Culture
• Day 1 Health Insurance, plus free dependent
• Fixed schedule and fixed weekends off
• Non-Toxic | Blended Non-Voice Account
• Employee Referral Incentive
• Opportunity for promotion

1. Audit

• Completing QA audits for their processes by following the QIP
• Providing feedback to team members on all errors
• Escalating any anomalies / trends / Compliance issues
• Performing the actual production work to keep abreast of the latest updates and practical scenarios
• Participating in client calls to capture process updates and monitoring compliance to the updates

2. Process

• Contact insurance carriers to verify patient’s insurance eligibility, benefits, and requirements. 
• Request, track, and obtain pre-authorization from insurance carriers within time allotted for medical and services.
• Review, request, follow up and secure authorizations for high dollar cost oncology chemotherapy drugs.
• Demonstrate and apply knowledge of medical terminology, high proficiency of general medical office procedures including HIPAA regulations. 
• Assist with medical necessity documentation to expedite approvals and ensure that appropriate follow-up is performed. 
• Review denials and follow up with provider to obtain medically necessary information to submit an appeal of the denial.
• Prioritize the incoming authorizations by level of urgency to the patient.
• Manage correspondence with insurance companies, physicians, specialists, and patients as needed, including documenting in the EHR as appropriate. 
• Respond to clinical questions regarding payer medical policy guidelines

• Must hold an active PHRN license (not a USRN license holder)
• Relevant experience as a Quality Auditor in Clinical Services within a healthcare BPO environment; alternatively, 4 to 7 years of specialized experience in Clinical Authorization or Utilization Review is preferred
• Strong familiarity with EPIC, MCG, or InterQual guidelines required
• Demonstrated job stability, with a consistent employment history and minimal transitions

Same as mentioned