Phrn Clinical Appeals Drg Specialist - 1 Year Drg Appeals Exp Bpo

Directpath Recruitment; Philippines; Remote; PHP 781,000 - 949,000; Full time

Job summary

Directpath Recruitment is seeking an experienced Registered Nurse (PHRN) with a strong Clinical Appeals DRG background to join our Healthcare BPO team working from home in the Philippines.

You will review inpatient records, prepare appeal letters, and support accurate reimbursement using DRG guidelines, MS-DRG/APR-DRG, and ICD-10-CM/PCS. Night shift is required.

Qualifications

• Active Philippine Registered Nurse (PHRN) license required.
• Minimum 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.

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.

Skills

PHRN License

1+ year DRG Appeals

Clinical Appeals Writing

DRG Downcoding

MS-DRG/APR-DRG knowledge

MCG/InterQual Guidelines

ICD-10-CM/PCS Coding

Analytical skills

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.