Clinical Denial Appeals

PM Consulting; Philippines; On-site; PHP 781,000 - 1,228,000; Full time

Job summary

PM Consulting seeks a Clinical Appeals Specialist in the Philippines to review denied claims, prepare clinical summaries, and submit retro-authorizations following payer guidelines and HIPAA requirements. You will build strong, well-documented appeals and track them through resolution.

The role requires 1 year of appeals writing, 3–5 years of acute care hospital experience (2–3 in ICU), a BSN, active PHRN/USRN license, and proficiency with EMR systems (Epic/Cerner/Meditech) plus InterQual/MCG

Qualifications

• At least 1 year of clinical appeals writing experience.
• 3–5 years of acute care clinical experience in a hospital setting (2–3 years if ICU).
• Bachelor of Science in Nursing (BSN).
• Active PHRN or USRN license.
• Strong knowledge of U.S. healthcare systems, insurance regulations, and RCM processes.
• Proficiency in InterQual or MCG clinical guidelines.
• Experience with EMR systems such as Epic, Cerner, or Meditech.
• Excellent verbal and written English communication skills (minimum CEFR B2).

Responsibilities

• Review and evaluate denied claims, including payer policies and clinical documentation
• Submit retro-authorizations in response to authorization denials
• Conduct medical necessity reviews and prepare supporting clinical summaries
• Write and submit detailed, well-supported appeals based on clinical documentation and payer guidelines
• Track, document, and follow up on all appeals through resolution
• Maintain accurate and timely communication with payers and internal stakeholders
• Perform research to support appeals and stay updated on payer policies and best practices
• Monitor and analyze denial trends and root causes
• Escalate patterns and issues to management with recommendations
• Assist in preparing and maintaining reports related to denials and appeals
• Collaborate with teams to improve processes and reduce A/R
• Ensure compliance with HIPAA, company policies, and regulatory requirements
• Identify and report billing discrepancies and compliance risks
• Participate in process improvement and system enhancement initiatives
• Engage in ongoing professional development and training

Skills

Clinical appeals writing

Acute care experience

English communication

US healthcare systems

RCM knowledge

HIPAA compliance

Education

Bachelor of Science in Nursing

Tools

Epic

Cerner

Meditech

Job description

• Review and evaluate denied claims, including payer policies and clinical documentation


• Submit retro-authorizations in response to authorization denials


• Conduct medical necessity reviews and prepare supporting clinical summaries


• Write and submit detailed, well-supported appeals based on clinical documentation and payer guidelines


• Track, document, and follow up on all appeals through resolution


• Maintain accurate and timely communication with payers and internal stakeholders


• Perform research to support appeals and stay updated on payer policies and best practices

Tracking, Reporting, and Trends:

• Monitor and analyze denial trends and root causes


• Escalate patterns and issues to management with recommendations


• Assist in preparing and maintaining reports related to denials and appeals


• Collaborate with teams to improve processes and reduce A/R

Compliance and Continuous Improvement:

• Ensure compliance with HIPAA, company policies, and regulatory requirements


• Identify and report billing discrepancies and compliance risks


• Participate in process improvement and system enhancement initiatives


• Engage in ongoing professional development and training

Qualifications:

Required:

• At least 1 year of clinical appeals writing experience


• 3–5 years of acute care clinical experience in a hospital setting (2–3 years if ICU)


• Bachelor of Science in Nursing (BSN)


• Active PHRN or USRN license


• Strong knowledge of U.S. healthcare systems, insurance regulations, and RCM processes


• Proficiency in InterQual or MCG clinical guidelines


• Experience with EMR systems such as Epic, Cerner, or Meditech


• Excellent verbal and written English communication skills (minimum CEFR B2)