Clinical BP_2026

Concentrix; Caloocan; On-site; PHP 400,000 - 600,000; Full time

Job summary

Concentrix is seeking a skilled Appeals PHRN Specialist to support the Medicare line of business. The role focuses on review, validation, and timely resolution of appeal cases in alignment with CMS guidelines.

Responsibilities include collaboration with payer nurses and IROs, documentation of clinical rationales, and maintaining meticulous case records while ensuring high-quality, efficient outcomes.

Qualifications

• Experience in Medicare UM or Appeals.
• Strong written and verbal communication skills in English.
• Ability to follow CMS guidelines and clinical criteria.

Responsibilities

• Review, evaluate, and process appeal requests for Medicare members per CMS regulations and protocols.
• Perform thorough case validation and clinical review to determine medical necessity and appropriate resolutions.
• Collaborate with onshore payer nurses and IROs to collect and verify documentation for appeals.
• Provide clear documentation and clinical rationales for approval or denial decisions.
• Maintain accurate records of all case activities and communicate findings across teams.
• Manage multiple appeal cases concurrently while meeting CMS-mandated turnaround times.
• Contribute to internal quality assurance and process improvement initiatives.
• Stay current on CMS guidelines and regulatory updates.

Skills

Medicare UM & Appeals

Clinical review

CMS guidelines

InterQual/MCG criteria

Documentation & communication

English proficiency

Education

Licensed RN (Philippines)

Tools

Microsoft Word

Microsoft Excel

Microsoft Outlook

Job description

Job Description:

Clinical BP_2026

Job Description

We are seeking a highly skilled and detail-oriented Appeals PHRN Specialist to support our expanding Medicare line of business. The ideal candidate will have a strong background in Utilization Management (UM), appeals processing, and case validation, with hands-on experience in Medicare UM or Appeals. This role will be critical in ensuring high-quality clinical review, thorough case investigation, and timely resolution of appeal cases in accordance with CMS guidelines.

Appeals Review & Case Handling

• Review, evaluate, and process appeal requests for Medicare members in compliance with CMS regulations and organizational protocols.
• Conduct thorough case validation and clinical review using sound judgment and medical necessity criteria.

Collaboration

• Collaborate with onshore payer nurses and Independent Review Organizations (IROs) to collect and verify necessary documentation for appeal resolution.
• Escalate complex cases as needed, providing detailed summaries and clinical insights.

Documentation & Communication

• Provide clear documentation and clinical rationales for approval or denial decisions.
• Maintain accurate records of all case activities and communicate findings effectively across teams.

Multitasking & Quality Assurance

• Manage multiple appeal cases concurrently while maintaining high standards for quality and turnaround time.
• Contribute to internal quality assurance reviews and support process improvement initiatives.

Compliance & Industry Standards

• Stay current on CMS guidelines, UM criteria, and regulatory updates.
• Ensure all appeals are resolved within required timelines and documented appropriately.

Technical Skills

Recommended Minimum Skills Requirements (MSRs)

• Strong understanding of Medicare UM and Appeals processes.
• Familiarity with CMS guidelines, InterQual/MCG criteria, and clinical review standards.
• Proficiency in using clinical platforms, documentation systems, and Microsoft Office Suite (Word, Excel, Outlook).

Soft Skills

• Strong case investigation, validation, and critical thinking abilities.
• Excellent written and verbal communication skills in English.
• High attention to detail, empathy, and sound clinical judgment.

Operational And Communication Skills

• Ability to manage multiple cases and meet CMS-mandated turnaround times.
• Strong organizational, documentation, and time management skills.
• Comfort working with cross-functional teams including payer nurses and IROs.

Requirements: