Clinical BP_2026

Convergys; Quezon City; On-site; PHP 446,400 - 669,600; Full time

Job summary

A global technology and services leader is seeking a detail-oriented Appeals PHRN Specialist to support their expanding Medicare line. The role involves evaluating appeals requests, collaborating with healthcare professionals, and ensuring compliance with CMS guidelines. Candidates should have strong experience in Utilization Management, excellent communication skills, and the ability to manage multiple cases effectively. The position is full time, located in Quezon City, Metro Manila, offering an engaging and impactful work environment.

Qualifications

• Strong understanding of Medicare UM and Appeals processes.
• Excellent written and verbal communication skills in English.
• Ability to manage multiple cases and meet CMS-mandated turnaround times.

Responsibilities

• Review and process appeal requests for Medicare members.
• Collaborate with onshore payer nurses and IROs.
• Document and communicate findings effectively across teams.

Skills

Utilization Management (UM)

Appeals processing

Case validation

Clinical review skills

Critical thinking

Communication skills

Tools

Microsoft Office Suite

Job description

Job Title:Clinical BP\_2026Job DescriptionWe 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 FloorLanguage Requirements:Time Type:Full time# **Mission:**### Hi, we're Concentrix. We’re 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 world's 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 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.