PHRN Urgent Opening! Clinical Appeals Specialist

Concentrix Philippines; Quezon City; On-site; PHP 420,000 - 540,000; Full time

Job summary

Concentrix Philippines is seeking an experienced Clinical Appeals Specialist (PHRN) to review, process, and resolve appeal cases in compliance with NCQA, CMS standards, and client guidelines.

You will support documentation, member communications, and quality targets while upholding confidentiality and privacy in a fast-paced environment with flexible US hours.

Qualifications

• Active Philippine Registered Nurse (PHRN) with license required.
• Minimum 1 year of clinical nursing experience in hospital, clinic, or managed care setting.
• Minimum 6 months of clinical process outsourcing experience with clinical appeals and utilization management.

Responsibilities

• Review appeal cases submitted by members, providers, and authorized representatives for Medicare Part C services.
• Evaluate clinical appropriateness based on medical necessity, benefits, and CMS guidelines.
• Document appeal decisions clearly in CMS-compliant formats and client protocols.
• Ensure timely processing within CMS turnaround times.
• Collaborate with medical directors and internal teams to gather required clinical information.
• Draft clear member/provider correspondence based on outcomes.
• Support the appeals quality program and implement feedback for improvement.
• Maintain confidentiality, data privacy, and HIPAA compliance.
• Escalate complex or high-risk cases as needed.
• Participate in training and calibration to maintain regulatory knowledge.

Skills

Clinical nursing experience

HIPAA awareness

Verbal communication

Written communication

Case management

Multitasking under pressure

Education

PHRN license (Philippine Registered Nurse)

Tools

Microsoft Word

Microsoft Excel

Microsoft Outlook

Job description

About the role

The Clinical Appeals Specialist (PHRN) is responsible for the review, processing, and resolution of appeal cases in compliance with NCQA and if applicable, CMS regulatory standards and client specific guidelines. You will ensure timely and clinically sound appeal determinations, upholding member rights and health plan obligations under commercial and CMS regulations. You will also support case documentation, member and provider communications, and contribute to the quality and compliance targets of the payor program.

Key responsibilities

• Review and assess appeal cases submitted by members, providers, and authorized representatives for Medicare Part C services
• Evaluate the clinical appropriateness of initial determinations based on medical necessity, benefit coverage, and guidelines determined and implemented by CMS
• Document appeal decisions clearly, accurately, and in compliance with CMS requirements and client specific protocols
• Ensure timely processing of appeal cases within the regulatory turnaround times set by CMS
• Collaborate with medical directors, case reviewers, and internal departments to gather required clinical information for appeal resolution
• Draft clear and compliant member and/or provider correspondence letters based on appeal outcomes
• Support the appeals quality program by participating in self-audits and implementing feedback for continuous improvement
• Uphold high levels of confidentiality, data privacy, and HIPAA compliance standards
• Escalate complex or high-risk cases to medical directors or appeals leadership as required
• Participate in training, calibration, and performance discussions to maintain clinical and regulatory knowledge

About you

• Active Philippine Registered Nurse (PHRN) with license required
• Minimum 1 year of clinical nursing experience in hospital, clinic, or managed care setting
• Minimum 6 months of clinical process outsourcing experience with background handling clinical roles focusing on clinical appeals and utilization management
• Strong clinical knowledge particularly in medical necessity review and interpretation of clinical documentation
• Good knowledge and understanding of different healthcare insurance processes, appeals, grievances, and utilization management (preferred)
• Excellent verbal and written communication skills
• Strong attention to detail and case documentation practices
• Able to manage multiple cases while meeting regulatory turnaround times under pressure
• Proficient in basic Microsoft Office applications such as Word, Excel, and Outlook
• Willing to work on flexible work schedules including US hours and holidays

Benefits

• Interact and collaborate with industry experts
• Multiple opportunities for learning and development
• Fun and competitive working environment

About us

Concentrix is the leading global provider of CX and tech services.