Clinical Denials & Appeals Specialist

Outsourcey; Taguig; On-site; PHP 670,000 - 1,339,000; Full time

Job summary

Outsourcey is seeking a Clinical Reviewer Specialist to maximize reimbursement by reviewing denied claims, analyzing medical records, and guiding appeal strategies. You will collaborate with providers and revenue cycle teams to obtain documentation and develop persuasive appeals, addressing recurring denial patterns.

The role requires clinical credentials, coding and reimbursement knowledge, strong written and verbal communication, and attention to detail.

Qualifications

• Health Information Management degree is preferred.
• Active certifications in coding are preferred (CCS/CPC/CIC).
• At least 3 years in healthcare revenue cycle, billing, claims processing, or denial management.
• Willingness to travel to clients or sites as needed.
• IP DRG Coding, Inpatient Surgery Coding, Inpatient E&M / Professional Coding, Inpatient HCC knowledge.

Responsibilities

• Review denied claims to determine denial reason, discrepancies, and appeal opportunities.
• Analyze medical records, billing, coding information, and payer correspondence to assess denial validity.
• Research payer policies, reimbursement guidelines, and regulatory requirements.
• Apply ICD-10-CM/PCS, CPT, HCPCS, modifiers to identify coding-related denial issues.
• Evaluate documentation to ensure services are supported and properly documented.
• Develop persuasive appeal arguments with clinical evidence and coding guidelines.
• Communicate clearly with providers to present appeal arguments.
• Maintain keen attention to detail in reviewing denials and medical records.
• Perform other duties as assigned.

Skills

Clinical expertise

Coding knowledge

Analytical ability

Written and verbal communication

Attention to detail

Education

Health Information Management

Tools

Epic EHR

Job description

Outsourcey is seeking a Clinical Reviewer Specialist to maximize reimbursement by reviewing denied claims, analyzing medical records, and guiding appeal strategies. You will collaborate with providers and revenue cycle teams to obtain documentation and develop persuasive appeals, addressing recurring denial patterns.

The role requires clinical credentials, coding and reimbursement knowledge, strong written and verbal communication, and attention to detail.