Clinical BP_2026

Concentrix; Quezon City; Sur place; PHP 420 000 - 660 000; Plein temps

Résumé du poste

Concentrix in Quezon City is seeking an Appeals PHRN Specialist to support Medicare line, focusing on case validation, medical necessity, and timely appeal resolution.

The role requires strong UM and appeals experience, CMS guideline familiarity, and solid English communication; you will collaborate with onshore payer nurses and IROs to gather documentation and ensure quality, with emphasis on accuracy and turnaround.

Qualifications

• Familiarity with CMS guidelines and Medicare UM/Appeals.
• Experience with documentation systems and clinical platforms.
• Excellent written and verbal English communication.

Responsabilités

• Review and process Medicare appeal requests in compliance with CMS.
• Conduct case validation and clinical review using medical necessity criteria.
• Collaborate with payer nurses and IROs to gather documentation.
• Provide clear documentation and rationale for decisions.
• Manage multiple cases and meet CMS turnaround times.

Connaissances

CMS guidelines

InterQual/MCG

UM experience

Appeals processing

Clinical judgment

English proficiency

Outils

MS Office Suite

Description du poste

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.

Recommended Minimum Skills Requirements (MSRs) Technical Skills:

• 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.

Location: PHL Quezon City - Tera Tower 20th Floor

Language Requirements:

Time Type: Full time

Mission:

Hi, we're Concentrix. We are a global technology and services leader that powers the brands of the future. We help well‑known brands - the ones you use every day - improve their businesses with technology and integrated solutions, in over 70 countries.

Company Overview:

We power the brands of the future. Some call us a global technology and services leader. But we're so much more. Human-centered, tech-powered, intelligence fuelled. Every day we're busy helping over 2000 of the worldwide best brands solve their toughest business challenges. Whether it's ... designing game-changing brand experiences, building and scaling secure AI technologies, or building loyalty to drive revenue. We've got them covered. But how? We design, build, and run fully integrated, end‑to‑end solutions across the entire enterprise, at speed and scale. We're the strategic thinkers who designbrand-defining experiences. The technologists & engineers who buildsmarter solutions. And the operational experts who run it all and make it work seamlessly. By integrating strategy & design with data & analytics, enterprise technology, and digital operations. You could say, at the heart of everything we do lies a commitment to transform the way companies connect, interact, and grow across the world and into the future. Experience the power of Concentrix.

Concentrix CVG Corporation is an EEO/AA/M/F/Vet/Disability Employer.