Medicare Appeals Clinician & Case Validator

Concentrix; Quezon City; On-site; PHP 420,000 - 660,000; Full time

Job summary

Concentrix in Quezon City is seeking an Appeals PHRN Specialist to support Medicare line, focusing on case validation, medical necessity, and timely appeal resolution.

The role requires strong UM and appeals experience, CMS guideline familiarity, and solid English communication; you will collaborate with onshore payer nurses and IROs to gather documentation and ensure quality, with emphasis on accuracy and turnaround.

Qualifications

• Familiarity with CMS guidelines and Medicare UM/Appeals.
• Experience with documentation systems and clinical platforms.
• Excellent written and verbal English communication.

Responsibilities

• Review and process Medicare appeal requests in compliance with CMS.
• Conduct case validation and clinical review using medical necessity criteria.
• Collaborate with payer nurses and IROs to gather documentation.
• Provide clear documentation and rationale for decisions.
• Manage multiple cases and meet CMS turnaround times.

Skills

CMS guidelines

InterQual/MCG

UM experience

Appeals processing

Clinical judgment

English proficiency

Tools

MS Office Suite

Job description

Concentrix in Quezon City is seeking an Appeals PHRN Specialist to support Medicare line, focusing on case validation, medical necessity, and timely appeal resolution.

The role requires strong UM and appeals experience, CMS guideline familiarity, and solid English communication; you will collaborate with onshore payer nurses and IROs to gather documentation and ensure quality, with emphasis on accuracy and turnaround.