Clinical Appeals Nurse — Denials Advocate & Outcomes

Health Business Solutions LLC; Cebu City; On-site; PHP 360,000 - 480,000; Full time

Benefits offered by this job

Health benefits

Paid time off

Professional growth

Diversity & equal opportunity employer

Job summary

HBiz is seeking a Clinical Appeals Nurse to manage medical denials with clinical expertise in the appeals process. The role emphasizes analytical thinking, strong clinical practice, and health information management.

Responsibilities include reviewing documentation, submitting timely appeals, and applying Milliman or InterQual guidelines to justify medical necessity. Collaboration with providers and payers is essential to advocate for patient services and reimbursement.

Qualifications

• Active RN license in the Philippines; US license preferred.
• 2+ years bedside clinical experience in a hospital.
• 1+ year in clinical appeals or utilization management.
• BSN preferred; ADN required.
• Proficiency with Milliman or InterQual guidelines.
• Strong ICD-10 coding knowledge.
• Excellent written communication and organizational skills.

Responsibilities

• Review clinical documentation and denial rationales to build appeal cases.
• Submit appeals timely according to regulatory and insurer rules.
• Use Milliman/InterQual guidelines to justify medical necessity.
• Collaborate with providers, case managers, and insurers to gather info.
• Interpret ICD-10 coding to support submissions.
• Maintain detailed records of appeals and outcomes.
• Educate staff on payer changes and coding standards.
• Stay updated on healthcare regulations and payer policies.

Skills

Clinical appeals

ICD-10 coding

Milliman guidelines

InterQual guidelines

Written communication

Organizational skills

Team collaboration

Education

BSN preferred

ADN required

Tools

Milliman guidelines

InterQual guidelines

Job description

HBiz is seeking a Clinical Appeals Nurse to manage medical denials with clinical expertise in the appeals process. The role emphasizes analytical thinking, strong clinical practice, and health information management.

Responsibilities include reviewing documentation, submitting timely appeals, and applying Milliman or InterQual guidelines to justify medical necessity. Collaboration with providers and payers is essential to advocate for patient services and reimbursement.