Clinical Appeals Specialist - Impactful Denials & Appeals

Connext; Philippines; On-site; PHP 391,000 - 614,000; Full time

Benefits offered by this job

Life Insurance

HMO Insurance Coverage

20 Leave Credits

Job summary

Connext Global Solutions is seeking a Clinical Appeals Specialist to support a US-based client. You will review denials and appeals, apply medical necessity criteria, and coordinate with payers and peer reviews. Strong English communication and healthcare compliance knowledge are required.

Join a growing global team that values collaboration, accuracy, and timely, compliant submissions to improve patient outcomes and payer satisfaction.

Qualifications

• Knowledge of payer requirements, medical necessity criteria, and healthcare compliance.

Responsibilities

• Review denials, partial approvals, level-of-care reductions, and adverse medical necessity decisions.
• Identify the clinical, administrative, or payer-related reasons for denials.
• Prepare and submit reconsiderations and first- and second-level appeals.
• Review clinical records and apply ASAM, LOCUS, CALOCUS/CASII, and payer criteria.
• Coordinate peer-to-peer reviews, documentation, and payer follow-ups.
• Track appeal deadlines, determinations, outcomes, and denial trends while maintaining accurate records.

Skills

Payer requirements

Medical necessity criteria

Healthcare compliance

English communication

Job description

Connext Global Solutions is seeking a Clinical Appeals Specialist to support a US-based client. You will review denials and appeals, apply medical necessity criteria, and coordinate with payers and peer reviews. Strong English communication and healthcare compliance knowledge are required.

Join a growing global team that values collaboration, accuracy, and timely, compliant submissions to improve patient outcomes and payer satisfaction.