Remote Appeals Nurse Specialist - DRG & MCG Expert

EPSILON GROUP SERVICES INC.; Cebu City; Hybrid; PHP 781,000 - 949,000; Full time

Job summary

EPSILON GROUP SERVICES INC. seeks an experienced Appeals Nurse Specialist to review denied inpatient and outpatient medical claims and craft evidence-based clinical arguments to overturn denials. The role requires PHRN license, BS Nursing, and DRG/appeals expertise.

The position starts with onsite training in NCR or Cebu, with a transition to work-from-home setup subject to company policy. A strong understanding of MCG, InterQual, ICD-10, and ASPEN criteria is essential to succeed.

Qualifications

• Active Philippine Registered Nurse (PHRN) license – REQUIRED.
• BS Nursing degree.
• Minimum 1 year of Clinical Appeals Writing experience – REQUIRED.
• MUST HAVE Appeals DRG BPO experience.
• Knowledge of MCG and InterQual medical necessity guidelines.
• Strong knowledge of ICD-10 coding guidelines.
• Familiarity with SOFA, KDIGO, GLIMS, and ASPEN criteria.
• Experience with MS-DRG and APR-DRG concepts.

Responsibilities

• Review denied inpatient and outpatient medical claims and analyze denial rationales.
• Write comprehensive, medically defensible clinical appeal letters using patient-specific documentation and payer requirements.
• Apply MCG and InterQual guidelines to support medical necessity, admission decisions, and appropriate levels of care.
• Review clinical documentation, diagnoses, procedures, and coding issues using ICD-10 guidelines.
• Apply relevant clinical criteria, including SOFA, KDIGO, GLIMS, and ASPEN, to support specialized appeal rationales.
• Identify CDI and DRG-related documentation issues and support DRG downcode appeals.
• Review cases involving MS-DRG and APR-DRG concepts.

Skills

Appeals writing

Clinical documentation

ICD-10 coding

MCG & InterQual

DRG knowledge

MS-DRG & APR-DRG

NCR/Cebu residency

PHRN license

Education

BS Nursing

Job description

EPSILON GROUP SERVICES INC. seeks an experienced Appeals Nurse Specialist to review denied inpatient and outpatient medical claims and craft evidence-based clinical arguments to overturn denials. The role requires PHRN license, BS Nursing, and DRG/appeals expertise.

The position starts with onsite training in NCR or Cebu, with a transition to work-from-home setup subject to company policy. A strong understanding of MCG, InterQual, ICD-10, and ASPEN criteria is essential to succeed.