Medicare Appeals & Utilization Review Nurse

Concentrix Philippines; Quezon City; On-site; PHP 420,000 - 600,000; Full time

Job summary

Concentrix Philippines is seeking a highly skilled Appeals PHRN Specialist to support our Medicare line of business. The role focuses on utilization management, appeals processing, and case validation to ensure high-quality clinical reviews and timely resolutions in line with CMS guidelines.

You will collaborate with onshore payer nurses and IROs, document clinical rationales for approvals or denials, manage multiple cases, and contribute to QA and process improvements while maintaining strict

Qualifications

• Strong understanding of Medicare UM and Appeals processes.
• Familiarity with CMS guidelines, InterQual/MCG criteria, and clinical review standards.
• Proficiency in using clinical platforms, documentation systems, and Microsoft Office Suite (Word, Excel, Outlook).

Responsibilities

• Review, evaluate, and process appeal requests for Medicare members in compliance with CMS regulations and organizational protocols.
• Conduct thorough case validation and clinical review using sound judgment and medical necessity criteria.
• Collaborate with onshore payer nurses and IROs to collect and verify necessary documentation for appeal resolution.
• Escalate complex cases with detailed summaries and clinical insights.
• Provide clear documentation and clinical rationales for approval or denial decisions.
• Maintain accurate records of all case activities and communicate findings effectively across teams.
• Manage multiple appeal cases concurrently while maintaining high quality and turnaround time.

Job description

Concentrix Philippines is seeking a highly skilled Appeals PHRN Specialist to support our Medicare line of business. The role focuses on utilization management, appeals processing, and case validation to ensure high-quality clinical reviews and timely resolutions in line with CMS guidelines.

You will collaborate with onshore payer nurses and IROs, document clinical rationales for approvals or denials, manage multiple cases, and contribute to QA and process improvements while maintaining strict