Clinical Appeals Specialist — Flexible US Hours + Growth

Concentrix Philippines; Quezon City; On-site; PHP 550,000 - 850,000; Full time

Benefits offered by this job

Learning and development opportunities

Collaborative team environment

Dynamic work culture

Job summary

Concentrix Philippines seeks an experienced Clinical Appeals Specialist (PHRN) to review and resolve CMS/regulatory-compliant appeal cases. You will ensure timely determinations and accurate documentation, while communicating with members and providers.

You will bring 2+ years of clinical nursing experience and 1 year in clinical process outsourcing, with Interqual/MCG knowledge, and exposure to insurance processes. Flexible US hour availability is required.

Qualifications

• Active Philippine Registered Nurse (PHRN) with license.
• Minimum 2 years clinical nursing experience in hospital, clinic, or managed care setting.
• Minimum 1 year of clinical process outsourcing experience focusing on clinical appeals and utilization management (Interqual and MCG).
• Strong clinical knowledge in medical necessity review and documentation interpretation.
• Good knowledge of healthcare insurance processes, appeals, grievances, and utilization management (preferred).
• Excellent verbal and written communication skills.
• Strong attention to detail and case documentation practices.
• Able to manage multiple cases under regulatory turnaround times.
• Proficient in Word, Excel, and Outlook.
• Willing to work flexible schedules including US hours and holidays.

Responsibilities

• Review and assess appeal cases submitted by members, providers, and authorized representatives for Medicare Part C services.
• Evaluate clinical appropriateness of determinations based on medical necessity and CMS guidelines.
• Document appeal decisions clearly in CMS-compliant format.
• Ensure timely processing of appeals within CMS turnaround times.
• Collaborate with medical directors and internal teams to gather required information for resolution.
• Draft compliant member/provider correspondence based on outcomes.
• Support quality program through self-audits and process feedback.
• Uphold confidentiality, data privacy, and HIPAA standards.
• Escalate complex or high-risk cases to leadership when needed.
• Participate in training and calibration to maintain regulatory knowledge.

Skills

2+ years clinical nursing experience

1 year clinical process outsourcing

Interqual and MCG knowledge

MS Office (Word/Excel/Outlook)

Education

Philippine Nursing License (PHRN)

Tools

MS Office

Job description

Concentrix Philippines seeks an experienced Clinical Appeals Specialist (PHRN) to review and resolve CMS/regulatory-compliant appeal cases. You will ensure timely determinations and accurate documentation, while communicating with members and providers.

You will bring 2+ years of clinical nursing experience and 1 year in clinical process outsourcing, with Interqual/MCG knowledge, and exposure to insurance processes. Flexible US hour availability is required.