Clinical Appeals Specialist (PHRN) — CMS Compliance

Concentrix; Quezon City; On-site; PHP 480,000 - 720,000; Full time

Job summary

Concentrix is seeking a Clinical Appeals Specialist (PHRN) in the Philippines to review and resolve appeal cases for Medicare Part C services, ensuring medical necessity and CMS guideline alignment. The role emphasizes accurate documentation and timely processing while upholding privacy and confidentiality.

You will work with medical directors and care teams to gather required information, draft communications, and support quality improvement initiatives within client guidelines and regulatory

Qualifications

• Active Philippine Registered Nurse (PHRN) with license
• Minimum 2 years of clinical nursing experience in hospital, clinic, or managed care setting
• Minimum 1 year of clinical process outsourcing experience handling 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
• Able to manage multiple cases and meet regulatory turnaround times under pressure
• Proficient in Word, Excel, and Outlook

Responsibilities

• Review and assess appeal cases submitted by members, providers, and authorized representatives for Medicare Part C services
• Evaluate the clinical appropriateness of initial determinations based on medical necessity, benefit coverage, and CMS guidelines
• Document appeal decisions clearly in compliance with CMS requirements and client protocols
• Ensure timely processing of appeal cases within CMS turnaround times
• Collaborate with medical directors and internal teams to gather required clinical information for appeal resolution
• Draft clear member and/or provider correspondence letters based on appeal outcomes
• Support the appeals quality program through self-audits and feedback implementation
• Maintain confidentiality, data privacy, and HIPAA compliance standards
• Escalate complex or high-risk cases to leadership as required
• Participate in training and performance discussions to maintain clinical and regulatory knowledge

Skills

Registered Nurse

PHRN license

Communication skills

Attention to detail

MS Office

Tools

Microsoft Office

Job description

Concentrix is seeking a Clinical Appeals Specialist (PHRN) in the Philippines to review and resolve appeal cases for Medicare Part C services, ensuring medical necessity and CMS guideline alignment. The role emphasizes accurate documentation and timely processing while upholding privacy and confidentiality.

You will work with medical directors and care teams to gather required information, draft communications, and support quality improvement initiatives within client guidelines and regulatory