PHRN - Clinical Denials and Appeals

Gratitude Philippines; Taguig; On-site; PHP 360,000 - 600,000; Full time

Job summary

A healthcare solutions provider in Metro Manila is seeking a PH Registered Nurse to handle medical necessity appeals. The role requires strong English communication skills and a willingness to work night shifts. The ideal candidate should have experience in EOBs and understanding denial causes, ensuring proper account management until resolution. This position offers an onsite opportunity in Taguig.

Qualifications

• Registered Nurse with experience in medical necessity appeals.
• Proficient in reading EOBs and investigating denial root causes.
• Willing to work night shifts.
• Skilled in navigating payer/provider portals.
• Typing speed 45 WPM.
• Strong English communication skills, spoken and written.
• Willing to work night shifts to liaise with payers.
• MCG and InterQual familiarity is a plus.
• Must NOT hold a USRN license.

Responsibilities

• Review medical necessity and authorization denials.
• Utilize payer policies to determine criteria for appeal.
• Write appeal letters using clinical indicators.
• Document in the EMR and prepare appeal packages per Client SOPs.
• Manage accounts until payment, write-off, transfer, or other adjudication.
• Report quality results, track educational opportunities, and provide training.

Skills

PH Registered Nurse

Reading Explanation of Benefits (EOB)

Navigating various payer and provider portals

Typing speed of at least 45 WPM

Strong command of the English language

Familiarity with MCG and InterQual

Education

PH Registered Nurse

Tools

EMR system

MCG criteria

InterQual criteria

Job description

Work set up: Onsite Opportunity – MCK Taguig, Cyber Sigma Building

Work schedule: Weekdays Night Shift schedule, Fixed Weekends Off

Responsibilities

• Effectively review inpatient and/or outpatient medical necessity and authorization denials to determine and understand the validity of such denials in a timely manner -- Should conduct comprehensive reviews of the claim denial and account, to make determinations of what action to be taken to obtain reimbursement.
• Utilize payer policies, MCG and InterQual criteria to determine if account meets criteria for appeal
• Should write an appeal letter to payer using appropriate clinical indicators, citing Official Coding Guidelines, and documentation from within the patient's medical record
• Perform all other necessary steps on the specified accounts per Clients SOP’s including documentation in the EMR, including appeal package creation
• Manage the accounts until payment is received, the account is written-off, transferred to patient-liability, or other adjudication / movement within the system that is appropriate and agreed upon by both Parties
• Reporting quality results, tracking and trending of educational opportunities of the coding and CDI specialists, responding to client subject matter needs, and providing educational support and training

Qualifications

• PH Registered Nurse with experience in doing medical necessity appeals, lack of authorization appeals.(6 months needed)
• Proficient in reading Explanation of Benefits (EOB) and investigating denial root causes.
• Must be skilled in navigating various payer and provider portals.
• Typing speed of at least 45 WPM.
• Strong command of the English language, both spoken and written.
• Willing to work night shifts to communicate with payers.
• Familiarity with MCG and InterQual is a plus.
• Must NOT hold a USRN license