Clinical Denials & Appeals Specialist

Outsourcey Global, Inc.; Taguig; On-site; PHP 600,000 - 900,000; Full time

Job summary

Outsourcey Global, Inc. is seeking a Clinical Reviewer Specialist to help maximize healthcare reimbursement by reviewing denied claims and crafting persuasive appeals. You will analyze medical records, coding, and payer policies to determine denial validity and opportunities for recovery.

You will collaborate with providers and revenue cycle teams to gather documentation, develop appeals, and address recurring denial patterns, applying ICD-10-CM/PCS, CPT, HCPCS, and relevant regulations.

Qualifications

• Minimum of 3 years of experience in healthcare revenue cycle management, medical billing, claims processing, or denial management.
• Completion of regulatory/mandatory certifications as required.
• Active preferred certifications – Coding Certification needed.
• IP DRG Coding, Inpatient Surgery Coding, Inpatient E&M / Professional Coding, Inpatient HCC / Risk Adjustment Coding.
• Experience with EHR systems, such as Epic, and payer denial management portals (preferred).

Responsibilities

• Demonstrate and consistently apply the Client's Core Values when interacting with team members, clients, providers, payers, and other stakeholders.
• Review denied claims to determine the specific denial reason, identify discrepancies, and assess opportunities for appeal.
• Analyze medical records, clinical documentation, billing records, coding information, and payer correspondence to determine the validity of denials.
• Research and interpret payer medical policies, reimbursement guidelines, contractual requirements, and applicable regulatory requirements.
• Apply knowledge of ICD-10-CM/PCS, CPT, HCPCS, modifiers, and other coding principles to identify coding-related denial issues and validate claim accuracy.
• Evaluate clinical documentation and supporting evidence to determine whether services were appropriately documented and supported.
• Develop clear, concise, and persuasive appeal arguments supported by clinical evidence, coding guidelines, payer policies, and applicable regulations.
• Communicate clearly and persuasively, both verbally and in writing, to collaborate with healthcare providers and present appeal arguments.
• Apply keen attention to detail to ensure accurate review and analysis of denied claims and medical records.
• Perform other duties as assigned.

Skills

Problem solving

USRN license

CDAS certification

Willingness to travel

Epic EHR experience

Education

Health Information Management or related field

Tools

Epic EHR

Payer denial portals

Job description

Outsourcey Global, Inc. is seeking a Clinical Reviewer Specialist to help maximize healthcare reimbursement by reviewing denied claims and crafting persuasive appeals. You will analyze medical records, coding, and payer policies to determine denial validity and opportunities for recovery.

You will collaborate with providers and revenue cycle teams to gather documentation, develop appeals, and address recurring denial patterns, applying ICD-10-CM/PCS, CPT, HCPCS, and relevant regulations.