Location: Guadalajara (On-Site, FTE)
Compensation: Competitive remuneration (approx. $23,000 MXN/month gross), annual performance-based bonus, and standard industry benefits.
Key Responsibilities:
- Review admissions and service requests (prospective, concurrent, and retrospective) to determine medical necessity and compliance with reimbursement policies.
- Collaborate with physicians and healthcare teams to ensure appropriate documentation, case justification, and discharge planning.
- Identify and address inappropriate admissions or denials; notify healthcare teams of reimbursement-impacting decisions.
- Act as liaison between the Physician Advisor and attending physicians to support accurate documentation and clinical appeals.
- Support denial resolution processes and ensure all communications with payors are properly documented and escalated when needed.
- Communicate efficiently with third-party payors, physicians, patients/families, and internal stakeholders.
- Participate in utilization and peer review meetings, providing insight on clinical documentation, treatment duration, and justification.
Required Competencies and Skills:
- Excellent written and spoken English
- Medical Doctor with active license
- Experience in clinical review, case management, or utilization review of insurance matters is a plus.