Clinical Denials & Appeals Nurse Specialist – IP & OP

MicroSourcing; Philippines; On-site; PHP 680,760 - 837,000; Full time

Job summary

MicroSourcing in Taguig, Metro Manila, Philippines, seeks a Clinical Denials & Appeals Nurse Specialist – IP & OP for a full-time, on-site night-shift role with a monthly salary of PHP 61,000–75,000. The position focuses on denials, appeals, and documentation management within a healthcare setting.

The ideal candidate reviews clinical documentation, drafts persuasive appeals, and tracks outcomes while ensuring compliance with HIPAA and payer policies.

Qualifications

• At least 1 year of clinical appeal writing experience.
• 3–5 years of acute care clinical experience in hospital setting; 2–3 years ICU.
• Bachelor of Science in Nursing.
• Registered Nurse license active (PHRN or USRN).
• Proficiency with InterQual or MCG guidelines; knowledge of U.S. government programs and insurance regulations.
• Experience with hospital EMRs such as Epic, Cerner, or Meditech.
• Excellent English communication (CEFR level B2).

Responsibilities

• Work denials and appeals in a timely manner; evaluate denial reasons and review clinical documentation.
• Submit retro-authorizations per payor requirements.
• Conduct medical necessity reviews for appeals and prepare summaries.
• Write and submit written appeals with supporting documentation; track outcomes.
• Document actions and follow up with payers to resolve denials and appeals.
• Track denial trends and escalate to management as needed.
• Collaborate on process improvements to address denial patterns and AR.
• Prepare and submit required compliance reports.

Skills

Clinical appeals writing

Medical documentation review

English communication

Analytical thinking

HIPAA compliance

Education

BSN (Bachelor of Science in Nursing)

RN license (PHRN/USRN)

Tools

Epic

Cerner

Meditech

Microsoft Office

SharePoint

Job description

Clinical Denials & Appeals Nurse Specialist – IP & OP

Taguig, Metro Manila, Philippines

Full-Time, On-Site, Night shift

Compensation: 61,000‑75,000 PHP per month

Responsibilities

• Work denials and appeals in a timely manner, evaluating the denial reason and reviewing clinical documentation to complete the next steps.
• Submit retro‑authorizations pursuant to payor requirements in response to authorization denials.
• Conduct medical necessity reviews based on denial root cause and prepare required clinical documentation summaries for appeals.
• Write and submit written appeals that include compelling arguments based on clinical documentation, third‑party payer medical policies, and contract language; track appeals through final outcome.
• Document all actions taken and follow up promptly to resolve denials and appeals with third‑party payers.
• Track the status and progress of denials and appeals across the organization.
• Research best practices and policy reforms, completing relevant research to assist the appeal process.
• Execute internal and external correspondence accurately, clearly, concisely, and professionally, following organizational regulations.
• Handle all communications, including telephone, electronic, and paper correspondence from payers and departments within the business office.

Tracking, Reporting, and Trends

• Maintain data on the types of claims denied and the root causes of denials.
• Identify denial patterns and, when appropriate, escalate to management with sufficient information for root‑cause resolution.
• Collaborate with management to recommend process changes that address denial patterns and improve A/R and overall quality.
• Prepare, maintain, and submit required reports.

Compliance and Continuous Improvement

• Collaborate with team members to continually improve services and participate in process and quality improvement activities.
• Identify system improvement opportunities and contribute to testing system modifications.
• Conduct research to stay informed on best practices and policy reforms related to appeals.
• Comply with state and federal regulations, accreditation and compliance requirements, and Huron’s policies, including those regarding fraud and abuse, confidentiality, and HIPAA.
• Maintain a thorough understanding of federal and state regulations and specific payer requirements to identify and report billing compliance issues and payer discrepancies.
• Participate in ongoing professional development to enhance job knowledge and performance.
• Report all identified compliance risks to appropriate leadership.

Qualifications

• At least 1 year of clinical appeal writing experience.
• Minimum 3–5 years of acute care clinical experience in a hospital setting (Med/Surg or similar); 2–3 years of ICU experience.
• Bachelor of Science in Nursing.
• Registered Nurse licensed with an active PHRN or USRN license.
• Proficiency in InterQual or MCG clinical guidelines; broad knowledge of U.S. Government Programs and insurance regulations.
• Proficiency with hospital‑based electronic medical records such as Epic, Cerner, or Meditech.
• Excellent verbal and written English communication skills and customer‑service skills (CEFR level at least B2).

Preferred Skills / Expertise

• Master’s degree or credential in business, healthcare, or related field.
• Case management or clinical appeals or clinical denials certification (ACMA) preferred.
• Proficiency with computer programs for tracking denials and appeals.
• Proficiency with Microsoft Office suite (Excel, Word, PowerPoint, Outlook, SharePoint).

Soft Skills

• Excellent attention to detail and strong follow‑up and follow‑through skills.
• Ability to make complex decisions independently and use judgment, discretion, and decision‑making abilities.
• Demonstrates teamwork and integrity in all work‑related activities.
• Professional interaction with internal and external customers.
• Strong analytical and critical‑thinking skills.
• Experience working in a matrixed environment.
• Excellent written and verbal communication skills.