Clinical BP_2026

Concentrix; Manila; On-site; PHP 500,000 - 750,000; Full time

Job summary

Concentrix seeks a highly skilled Appeals PHRN Specialist to support Medicare line, focusing on UM, appeals processing, and case validation. You will ensure high-quality clinical review and timely resolution of appeal cases in line with CMS guidelines.

Collaborate with payer nurses and IROs to collect documentation, perform thorough case investigations, and provide clear rationales for decisions. Maintain accurate records and meet CMS timelines with meticulous attention to detail.

Qualifications

• Strong background in Utilization Management (UM) and appeals processing.
• Experience with case validation and medical necessity criteria.
• Proficiency in CMS guidelines and clinical review standards.

Responsibilities

• Review and process Medicare appeal requests per CMS regulations.
• Conduct thorough case validation and clinical review.
• Provide clear documentation and rationales for decisions.
• Collaborate with payer nurses and IROs to verify documentation.
• Manage multiple cases while meeting turnaround times and QA standards.

Skills

Medicare UM

CMS guidelines

InterQual/MCG criteria

Microsoft Office

English communication

Tools

Clinical platforms

Documentation systems

Job description

Job Description:

Job Title

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.