Clinical Reviewer Specialist - Coding Certification Required

Outsourcey; Taguig; On-site; PHP 3,769,000 - 5,653,000; Full time

Job summary

Outsourcey seeks a Clinical Reviewer Specialist to review denied claims, analyze medical records and payer policies, and develop persuasive appeals. The role integrates clinical knowledge with coding and reimbursement guidelines to maximize reimbursement and reduce denials.

The candidate will collaborate with providers and revenue cycle teams, gather supporting documentation, and craft compelling appeals while maintaining high attention to detail. Travel to client sites may be required.

Qualifications

• Relevant degree in health information management or related field.
• Active coding certification preferred.
• Minimum 3 years in healthcare revenue cycle, billing, or denials.

Responsibilities

• Review denied claims to determine denial reason and opportunities for appeal.
• Analyze medical records, coding, and payer communications for validity.
• Develop persuasive appeal arguments with clinical evidence and guidelines.
• Collaborate with providers and revenue cycle teams to obtain documentation.
• Maintain attention to detail in reviewing denials and documentation.
• Travel to client sites as needed.

Skills

Healthcare revenue cycle

Medical billing

Denial management

Coding knowledge

Clinical documentation review

Appeal writing

Regulatory compliance

Travel willingness

Education

Health Information Management

Coding certification

Tools

Epic EHR

Payer portals

Job description

The Clinical Reviewer Specialist plays a critical role in maximizing healthcare reimbursement by reviewing denied claims, identifying root causes of denials, and developing clinically and technically sound appeal strategies.

This position reviews medical records, coding and billing documentation, payer policies, and other relevant clinical information to determine the validity of denials and identify opportunities for reimbursement recovery. The Clinical Reviewer Specialist collaborates with healthcare providers and revenue cycle teams to obtain supporting documentation, develop persuasive appeals, and address recurring denial patterns.

The successful candidate will combine clinical expertise, coding and reimbursement knowledge, analytical ability, and strong written and verbal communication skills to support both revenue recovery and denial prevention initiatives.

This is a work-from-office opportunity for a clinically credentialed professional seeking to make a measurable impact on financial performance, claim quality, and revenue cycle outcomes.

Duties and Responsibilities

Denial Review & Appeals

• 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
• Communicates clearly and persuasively, both verbally and in writing, to collaborate with healthcare providers and present appeal arguments.
• Applies keen attention to detail to ensure accurate review and analysis of denied claims and medical records.
• Performs other duties as assigned.

Qualifications

Required

• Health Information Management, or a related field.
• Active preferred certifications – Coding Certification needed.
• Minimum of 3 years of experience in healthcare revenue cycle management, medical billing, claims processing, or denial management.
• Strong problem-solving skills with the ability to develop effective appeal strategies.
• Completion of regulatory/mandatory certifications as required.
• Willingness and ability to travel to clients or organizational sites as needed.
• IP DRG Coding, Inpatient Surgery Coding, Inpatient E&M / Professional Coding, Inpatient HCC / Risk Adjustment Coding.

Preferred

• Certified Denials and Appeals Specialist (CDAS) or equivalent denial management credential.
• Experience with EHR systems, such as Epic, and payer denial management portals.
• Active USRN license

Physical Demands and Work Environment

• Work Environment: This job operates in a professional home environment. This role routinely uses standard office equipment such as computers and phones.
• Physical Demands: This is largely a sedentary role; however, employees may need to use keyboards, mouse, and other devices for typing, clicking, and navigating software systems.
• The employee must comply with Client’s Code of Conduct, policies, procedures, and guidelines.