Clinical Reviewer Specialist | Coding Certification Required | ONSITE | NIGHTSHIFT

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

Required Certifications: CCS, CPC, CIC; | CDAS preferred

About the Role

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.

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.
• 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

• 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.

Required Skills

• Clinical expertise.
• Coding and reimbursement knowledge.
• Analytical ability.
• Strong written and verbal communication skills.
• Keen attention to detail.

Preferred Skills

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