Clinical Appeals Specialist

PM Consulting; Metro Manila; On-site; PHP 3,708,282 - 4,944,376; Full time

Job summary

PM Consulting is seeking a Clinical Appeals Specialist to review and prepare appeals for denied healthcare claims. The role requires analyzing medical documentation and applying coding guidelines to support medical necessity.

The ideal candidate should have experience in clinical appeals writing and coding within the US healthcare environment, along with strong analytical and communication skills. This position allows for remote work.

Qualifications

• At least 6 months to 1+ year of Clinical Appeals Writing experience.
• Experience handling DRG downgrade appeals or coding appeals preferred.
• Strong understanding of ICD-10 coding guidelines.

Responsibilities

• Review denied healthcare claims and prepare appeal documentation.
• Analyze medical records to support medical necessity and coding accuracy.
• Prepare clear clinical appeal letters.

Skills

Clinical Appeals Writing

ICD-10 Coding

Critical Thinking

Analytical Skills

Written Communication

Job description

The Clinical Appeals Specialist is responsible for reviewing and preparing clinical and coding-related appeals for denied or downgraded healthcare claims. This role involves analyzing medical documentation, applying ICD-10 coding guidelines, and utilizing MCG/InterQual criteria to support medical necessity and DRG validation. The ideal candidate has experience in clinical appeals writing, medical coding, CDI, or DRG downgrade review within a US healthcare environment.

Key Responsibilities

• Review denied, downgraded, or disputed healthcare claims and prepare comprehensive appeal documentation
• Analyze medical records to support medical necessity and coding accuracy
• Interpret and apply ICD-10-CM/PCS coding guidelines, MCG, and InterQual criteria
• Evaluate DRG assignments, including MS-DRG and APR-DRG methodologies
• Prepare clear, concise, and evidence-based clinical appeal letters
• Collaborate with coding, CDI, utilization review, and clinical teams to gather supporting documentation
• Ensure compliance with payer guidelines, CMS regulations, and organizational standards
• Maintain productivity, quality, and turnaround time expectations
• Identify trends or recurring denial patterns and escalate concerns when necessary
• Participate in process improvement initiatives and team discussions

Qualifications

• At least 6 months to 1+ year of Clinical Appeals Writing experience
• Experience handling DRG downgrade appeals or coding appeals preferred
• Background in Medical Coding, Clinical Documentation Improvement (CDI), or DRG validation/review
• Strong understanding of ICD-10 coding guidelines
• Familiarity with MCG and/or InterQual guidelines
• Experience with MS-DRG and APR-DRG methodologies is highly preferred
• US healthcare industry experience required
• Excellent analytical, critical thinking, and written communication skills
• Ability to work independently in a remote setup