Clinical Appeals Nurse: Denials Resolution Specialist

Mynimo; Pasig; On-site; PHP 450,000 - 750,000; Full time

Benefits offered by this job

Health benefits

Paid time off

Professional growth opportunities

Job summary

HBiz is seeking a Clinical Appeals Nurse to lead denial reviews and prepare strong appeal cases. The ideal candidate is a licensed RN with hospital clinical experience and a background in utilization management.

The role emphasizes collaboration with clinicians and insurers to secure appropriate patient services and reimbursement. The position requires thorough documentation, adherence to guidelines, and ongoing education of staff on payer changes and coding standards.

Qualifications

• Active RN license in the Philippines; US license preferred.
• Minimum two years bedside hospital experience.
• At least one year in clinical appeals or utilization management.
• BSN preferred; ADN required.

Responsibilities

• Review clinical documentation and denial rationales to formulate appeal cases.
• Submit timely appeals according to regulatory and insurer requirements.
• Use Milliman/InterQual guidelines to substantiate medical necessity.
• Collaborate with providers, case managers, and insurers to gather information.
• Interpret ICD-10 codes to support appeals.
• Maintain records of appeals and outcomes.
• Educate clinical staff on payer requirements and documentation standards.
• Stay updated on healthcare regulations and payer policies.

Skills

Clinical documentation

ICD-10 coding

Utilization management

InterQual/Milliman guidelines

Communication skills

Organizational skills

Education

BSN preferred

ADN required

Tools

Milliman guidelines

InterQual guidelines

ICD-10 coding

Job description

HBiz is seeking a Clinical Appeals Nurse to lead denial reviews and prepare strong appeal cases. The ideal candidate is a licensed RN with hospital clinical experience and a background in utilization management.

The role emphasizes collaboration with clinicians and insurers to secure appropriate patient services and reimbursement. The position requires thorough documentation, adherence to guidelines, and ongoing education of staff on payer changes and coding standards.