Inpatient Appeals Nurse (USRN) / WFH

VEE HEALTHTEK PH INC.; Eastern Manila District; Remote; PHP 480,000 - 600,000; Full time

Job summary

VEE HEALTHTEK PH INC. is seeking an experienced Registered Nurse with strong Utilization Management and appeals expertise. The role requires US RN licensure and at least 2 years of bedside acute care experience, plus proven skills in handling denials and medical necessity reviews.

The ideal candidate will be proficient with MCG/InterQual guidelines, payer policies, and have excellent communication with physicians and payers. EMR proficiency and strong coding knowledge are essential.

Qualifications

• Minimum 2+ years of bedside clinical experience in an acute care hospital setting.
• Minimum 2+ years of experience in Utilization Management (UM), Prior Authorization, Denials Management, or Appeals Review.
• Extensive experience handling inpatient medical necessity appeals across Commercial, Medicare, Medicaid, and Managed Care payers.
• Strong knowledge of inpatient authorization denials, medical necessity denials, level-of-care determinations, procedure denials, medication denials, and retrospective reviews.
• Proficient in MCG, InterQual, CMS Medicare Guidelines, and commercial payer medical policies.
• Experience with first-level appeals, second-level appeals, reconsiderations, Peer-to-Peer (P2P) reviews, and medical necessity appeal letters.
• Knowledge of medical terminology, ICD-10, CPT, and basic coding concepts.
• Excellent written and verbal communication skills with physicians, payers, case managers, and leadership teams.
• Proficient in EMR systems, Microsoft Office, payer portals, and utilization management platforms.

Responsibilities

• Handle inpatient medical necessity appeals across Commercial, Medicare, Medicaid, and Managed Care payers.
• Apply knowledge of denials, level-of-care determinations, and retrospective reviews.
• Prepare and present medical necessity appeal letters and P2P reviews.
• Communicate effectively with physicians, payers, case managers, and leadership teams.

Skills

Clinical nursing experience

Communication skills

EMR proficiency

Payer/Utilization management knowledge

Education

Registered Nurse license (US RN)

Tools

EMR systems

Payer portals

Microsoft Office

Job description

• Active US Registered Nurse (RN) license; New York State RN license preferred.
• Minimum 2+ years of recent bedside clinical experience in an acute care hospital setting.
• Minimum 2+ years of experience in Utilization Management (UM), Prior Authorization, Denials Management, or Appeals Review.
• Extensive experience handling inpatient medical necessity appeals across Commercial, Medicare, Medicaid, and Managed Care payers.
• Strong knowledge of inpatient authorization denials, medical necessity denials, level-of care determinations, procedure denials, medication denials, and retrospective reviews.
• Proficient in MCG, InterQual, CMS Medicare Guidelines, and commercial payer medical policies.
• Experience with first-level appeals, second-level appeals, reconsiderations, Peer-to-Peer (P2P) reviews, and medical necessity appeal letters.
• Knowledge of medical terminology, ICD-10, CPT, and basic coding concepts.
• Excellent written and verbal communication skills with physicians, payers, case managers, and leadership teams.
• Proficient in EMR systems, Microsoft Office, payer portals, and utilization management platforms.