CLINICAL DENIALS & APPEALS Specialist_Onsite_Nightshift_BGC_Up to 75k

weSource Management Consultancy Firm; Taguig; On-site; PHP 761,670 - 912,330; Full time

Job summary

weSource Management Consultancy Firm is hiring a Clinical Denials & Appeals Specialist for onsite work in BGC Taguig. This role requires 1 year of appeals writing and 3 years of clinical experience, alongside an active PHRN or USRN license. The specialist will manage denials and appeals, conduct medical reviews, and submit necessary documentation, ensuring compliance with regulations. The compensation can go up to ₱75,000 based on experience.

Qualifications

• 1 year of Appeals Writing experience required.
• 3-5 years of acute care experience and 2-3 years in ICU are necessary.
• Active PHRN or USRN licensure required.

Responsibilities

• Manage denials and appeals, ensuring accurate processing.
• Submit retro-authorizations for denial cases.
• Conduct medical necessity reviews and document appeals.

Skills

Appeals Writing

Clinical experience

English proficiency (CEFR B2+)

InterQual/MCG knowledge

EMR systems (Epic, Cerner, Meditech)

Education

BS Nursing

Job description

We are hiring for a CLINICAL DENIALS & APPEALS Specialist for a client based in BGC Taguig.

This is an Onsite work following a Nightshift schedule.

Salary is up to ₱75,000.00based on experience.

Non-Negotiable Requirements:

• Must have 1 yr of Appeals Writing and 3 yrs of Clinical experience and must either be a PHRN or USRN
• Clinical: 3–5 years acute care + 2–3 years ICU
• Education: BS Nursing
• Licensure: Active PHRN or USRN
• RCM: InterQual/MCG + US payer/regulations knowledge
• Systems: EMR (Epic, Cerner, Meditech)
• Communication: English proficiency (CEFR B2+)

Other Requirements:

• Experience supporting international BPO clients
• Familiarity with ATS tools and recruitment metrics

Key Responsibilities:

• Denials and Appeals Management
• Work denials and appeals timely, evaluating the denial reason including information from the payor and payor policies, reviewing the clinical documentation, assessing options and completing next steps
• Submit retro‑authorizations in accordance with payor requirements in response to authorization denials
• Conducts medical necessity reviews, based on denial root cause, and prepares any required clinical documentation summaries to accompany appeals.
• Write and submit written appeals which include compelling arguments based on clinical documentation, third‑party payer medical policies, and contract language. Appeals are submitted timely and tracked through final outcome.
• Document all actions taken and follow‑up timely as needed related to resolving denials and appeals with third‑party payers in a timely manner
• Tracks the status and progress of denials and appeals
• Completes relevant research to assist with completing the appeals process and to stay informed on best practices and policy reforms
• Executes internal and external correspondence accurately, clearly, concisely, and professionally while following organizational regulations
• Effectively handles all communications, including telephone, electronic, and paper correspondence from payers and departments within the business office
• Tracking, Reporting, and Trends
• Maintains data on the types of claims denied and root causes of denials
• Identify denial patterns and elevate to management as appropriate with sufficient information for additional follow‑up, and/or root cause resolution
• Collaborate with management to recommend process changes to address root cause of denials and overall improvement to reduce A/R
• Prepares, maintains, assists with, and submits reports as required
• Compliance and Continuous Improvement
• Collaborate with team members to continually improve services, and engage in process and quality improvement activities
• Identify system improvement opportunities and contribute to the testing of system modifications
• Conducts relevant research to assist with completing the appeals process and to stay informed on best practices and policy reforms
• Complies with state and federal regulations, accreditation/compliance requirements, and Huron's policies, including those regarding fraud and abuse, confidentiality, and HIPAA
• Maintains a thorough understanding of federal and state regulations, as well as specific payer requirements and explanations of benefits, in order to identify and report billing compliances issues and payer discrepancies
• Participates in ongoing professional development to enhance job knowledge and performance
• Reports all identified compliance risks to appropriate leadership