Medicare Appeals Specialist - UM & Case Validation

Concentrix; Manila; On-site; PHP 500,000 - 750,000; Full time

Job summary

Concentrix seeks a highly skilled Appeals PHRN Specialist to support Medicare line, focusing on UM, appeals processing, and case validation. You will ensure high-quality clinical review and timely resolution of appeal cases in line with CMS guidelines.

Collaborate with payer nurses and IROs to collect documentation, perform thorough case investigations, and provide clear rationales for decisions. Maintain accurate records and meet CMS timelines with meticulous attention to detail.

Qualifications

• Strong background in Utilization Management (UM) and appeals processing.
• Experience with case validation and medical necessity criteria.
• Proficiency in CMS guidelines and clinical review standards.

Responsibilities

• Review and process Medicare appeal requests per CMS regulations.
• Conduct thorough case validation and clinical review.
• Provide clear documentation and rationales for decisions.
• Collaborate with payer nurses and IROs to verify documentation.
• Manage multiple cases while meeting turnaround times and QA standards.

Skills

Medicare UM

CMS guidelines

InterQual/MCG criteria

Microsoft Office

English communication

Tools

Clinical platforms

Documentation systems

Job description

Concentrix seeks a highly skilled Appeals PHRN Specialist to support Medicare line, focusing on UM, appeals processing, and case validation. You will ensure high-quality clinical review and timely resolution of appeal cases in line with CMS guidelines.

Collaborate with payer nurses and IROs to collect documentation, perform thorough case investigations, and provide clear rationales for decisions. Maintain accurate records and meet CMS timelines with meticulous attention to detail.