Medical Revenue Cycle Specialist – Pediatric Private Duty Nursing (PDN) | Philippines

The Medical Revenue Cycle Specialist is responsible for managing insurance verification, authorization requests, Single Case Agreements (SCAs), and reauthorization processes for Pediatric Private Duty Nursing (PDN) patients. This role ensures that required documentation is complete, authorization requests are submitted and tracked appropriately, payer requirements are met, and approvals are secured and documented before services begin.

The specialist works closely with Sales and Intake, Clinical, Scheduling, Recruiting, Accounting, and Operations teams to support timely patient onboarding, continuity of care, accurate authorization records, and compliance with payer requirements.

Key Responsibilities

1. New Case Intake and Insurance Verification

• Review new patient referrals and ensure all required demographic, insurance, and clinical information is collected before initiating authorization requests.
• Verify patient eligibility, coverage effective dates, primary and secondary insurance, member out-of-pocket responsibilities, and out-of-network benefits.
• Perform insurance verification through the appropriate payer portals, including the NJ Medicaid Portal and Availity, or by contacting insurance carriers directly.
• Identify authorization and Single Case Agreement (SCA) requirements for each insurance plan.
• Obtain and document Care Manager contact information, including name, phone number, and email address.
• Verify discharge dates for hospitalized patients before proceeding with authorization requests.
• Follow coordination-of-benefits requirements for patients with both commercial insurance and NJ Medicaid coverage.

2. Authorization and Single Case Agreement (SCA) Management

• Collect and review required clinical documentation, including the Letter of Medical Necessity (LOMN), diagnosis information, clinical notes, available medical records, and physician orders or Form 485 when available.
• Coordinate with the Clinical team to ensure documentation supports the requested nursing hours, frequency, and duration of services.
• Prepare and submit complete authorization packets to insurance companies' Utilization Management (UM) departments.
• Record submission dates, reference numbers, requested services, and other relevant authorization details.
• Monitor authorization requests and follow up with insurance carriers to obtain determinations and address outstanding requirements.
• Determine whether an SCA is required and coordinate the process for finalizing agreements when applicable.
• Support the SCA process by coordinating reimbursement rate discussions and documenting approved rates and service parameters.
• Identify cases that may require a Gap Exception and coordinate with the appropriate parties when an in-network pediatric home care provider is unavailable.
• Obtain and verify written authorization approvals, ensuring approved dates, hours, frequency, duration, and authorization numbers are accurately documented.
• Escalate delayed, incomplete, or denied authorization requests to the appropriate internal stakeholders.

3. Reauthorization and Authorization Expiration Tracking

• Maintain an accurate tracking system for authorization effective dates and expiration dates.
• Begin reauthorization preparation at least two weeks before the current authorization expires.
• Coordinate with the Clinical team to obtain the most recent two weeks of clinical notes, current physician orders or Form 485, nursing assessments, Plan of Care (POC), and updated LOMN when required.
• Reverify insurance eligibility, coordination of benefits, Care Manager information, and payer submission requirements.
• Review reauthorization packets for consistency across diagnosis, requested nursing hours, frequency, duration, and supporting documentation.
• Submit complete reauthorization requests before the current authorization expires.
• Monitor pending requests, follow up on outstanding items, and coordinate additional documentation, exception requests, or appeals as needed.
• Verify approved reauthorization details and ensure updated authorizations are entered into the appropriate systems before the new authorization period begins.

4. Appeals and Clinical Documentation Coordination

• Coordinate the collection of updated clinical documentation and medical necessity support for appeals and exception requests.
• Work with the Clinical team to obtain updated LOMNs and other supporting records when required.
• Track cases involving appeals, pending reauthorizations, or exception requests and ensure unresolved items are escalated for weekly clinical review.
• Coordinate payer requests for additional information and maintain accurate records of communications and case status.
• Ensure that requests for verbal clinical support are referred to a licensed nurse. The specialist does not independently provide clinical determinations or represent clinical necessity outside their qualifications.

5. Patient System Setup and Authorization Documentation

• Ensure patient authorization information and supporting documentation are accurately maintained in the designated systems.
• Coordinate patient setup in AlayaCare for all applicable cases and HHAeX for NJ Medicaid pediatric cases, in accordance with payer-specific requirements.
• Ensure approved authorization details are accurately entered or updated and communicated to Scheduling.
• Maintain complete patient records, including Care Manager contact information, authorization documents, approved hours, service dates, and relevant payer communications.
• Coordinate with Scheduling to ensure patient schedules and Master Week schedules, where applicable, align with approved service hours and authorization periods.
• Ensure required documentation is filed and accessible for operational review and quality assurance.

6. Compliance Monitoring and Operational Support

• Monitor authorization-related requirements that may affect service delivery, billing, or reimbursement.
• Coordinate with Scheduling and Recruiting to ensure required nurse compliance and credentialing updates are completed before service delivery.
• Support monitoring of Electronic Visit Verification (EVV) compliance for Medicaid cases and escalate identified issues to the responsible team.
• Help ensure nurses do not exceed authorized hours and that requests for additional hours receive Care Manager approval before services are provided.
• Coordinate with Accounting when shared cases or other service arrangements require notification.
• Support daily dashboard reviews, authorization-related exception resolution, and pre-billing issue escalation.
• Ensure patient status changes, including hospitalization and vacation status, are appropriately communicated to the responsible teams.
• Complete assigned quality assurance checklists for initial authorizations and reauthorizations before services begin or a new authorization period starts.

7. Reporting and Process Improvement

• Maintain accurate authorization trackers, expiration reminders, follow-up logs, and case status records.
• Monitor pending authorizations, upcoming expirations, incomplete documentation, and outstanding payer requirements.
• Maintain 30-day and 45-day reminders, as applicable to the case and payer requirements.
• Provide regular updates on authorization status, pending approvals, reauthorization progress, and potential service or billing risks.
• Identify recurring delays, documentation gaps, and process issues and recommend improvements to support timely authorization processing and operational efficiency.

Peak Support and our Work-from-Home PLUS model

At Peak Support, we are dedicated to providing exceptional service to our clients and an exceptional work environment for our team members.

We don’t do this with ping pong tables or video games. We do it by creating a positive, encouraging and performance-driven culture that enables our team members to build rewarding, long-term careers. We’re proud that our Glassdoor rating of 4.5 is the highest in the Business Process Outsourcing industry.

Peak Support offers all the convenience of working from home, with the benefits of working for an established organization with an exceptional team and tremendous opportunities for growth. Peak Support has been 100% remote since day one, so we have built a culture and a set of processes that support the success of our remote team members.