Inpatient Appeals RN | Utilization & Denials Expert

VEE HEALTHTEK PH INC.; Eastern Manila District; Remoto; PHP 480.000 - 600.000; Tempo pieno

Descrizione del lavoro

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.

Competenze

• 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.

Mansioni

• 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.

Conoscenze

Clinical nursing experience

Communication skills

EMR proficiency

Payer/Utilization management knowledge

Formazione

Registered Nurse license (US RN)

Strumenti

EMR systems

Payer portals

Microsoft Office

Descrizione del lavoro

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.