Phrn Clinical Appeals Drg Specialist - 1 Year Drg Appeals Exp

Ggas Services; Metro Manila; Remote; PHP 781,000 - 949,000; Full time

Job summary

Ggas Services is seeking an experienced Registered Nurse (PHRN) with a strong Clinical Appeals DRG background to join our Healthcare BPO team. This role involves reviewing inpatient medical records, evaluating clinical documentation, preparing clinical appeal letters, and supporting accurate reimbursement using industry-standard clinical guidelines.

You will work from home on the night shift, collaborating with coding and clinical teams to maximize reimbursement outcomes.

Qualifications

• Active Philippine Registered Nurse (PHRN) license is required.
• Minimum of 1 year of Clinical Appeals DRG experience in a Healthcare BPO.
• Clinical Appeals writing experience required.
• Experience with DRG downcoding.
• Knowledge of MS-DRG and/or APR-DRG.
• Familiarity with ICD-10-CM/PCS coding guidelines.

Responsibilities

• Review inpatient medical records and supporting clinical documentation.
• Prepare evidence-based clinical appeal letters for denied or downcoded claims.
• Evaluate medical necessity using DRG guidelines.
• Analyze payer denials related to DRG assignment and reimbursement.
• Validate diagnoses, procedures, and DRG assignments using ICD-10 guidelines.
• Collaborate with coding and clinical teams to maximize reimbursement outcomes.
• Meet quality, accuracy, and productivity standards.

Skills

PHRN License

Clinical Appeals DRG

1+ year DRG experience

DRG Downcoding

MCG/APR-DRG knowledge

ICD-10-CM/PCS

English communication

Night Shift

Job description

Registered Nurse (PHRN) | Clinical Appeals DRG Specialist | 1+ Year Clinical Appeals DRG Experience | Work From Home | ₱70K–₱85K

Salary Package: ₱70,000–₱85,000 (Depending on your skills, qualifications, relevant experience, and interview results.)

Work Setup: Work From Home

Work Location: Quezon City | Taguig City | Cebu City

Shift: Night Shift

About the Role

We are seeking experienced Registered Nurses (PHRN) with a strong background in Clinical Appeals DRG to join our Healthcare BPO team. This role involves reviewing inpatient medical records, evaluating clinical documentation, preparing clinical appeal letters, and supporting accurate reimbursement using industry-standard clinical guidelines.

Non-Negotiable Requirements

• Active Philippine Registered Nurse (PHRN) License
• Minimum of 1 year of Clinical Appeals DRG experience in a Healthcare BPO
• Clinical Appeals Writing experience
• Experience with DRG Downcoding
• Knowledge of MS-DRG and/or APR-DRG
• Experience using MCG and/or InterQual Guidelines
• Familiarity with ICD-10-CM/PCS Coding Guidelines
• Strong analytical, documentation review, and clinical decision-making skills
• Excellent written and verbal English communication skills
• Willing to work Night Shift

Key Responsibilities

• Review inpatient medical records and supporting clinical documentation.
• Prepare evidence-based clinical appeal letters for denied or downcoded claims.
• Evaluate medical necessity using MCG and InterQual Guidelines.
• Analyze payer denials related to DRG assignment and reimbursement.
• Validate diagnoses, procedures, and DRG assignments using ICD-10 coding guidelines.
• Collaborate with coding and clinical teams to maximize reimbursement outcomes.
• Meet quality, accuracy, and productivity standards.

Important – Please Read Before Applying

Your application will undergo an initial resume paper screening.

Applications will be automatically rejected if your resume does not clearly demonstrate:

• At least 1 year of Clinical Appeals DRG experience in a Healthcare BPO
• Clinical Appeals Writing experience
• DRG Downcoding experience

If your Clinical Appeals DRG experience is not clearly reflected in your work history, your application will not proceed to the next stage. Please update your resume before submitting your application.