Remote PHRN Clinical Appeals Specialist — Growth & Impact

Concentrix Philippines; Philippines; Remote; PHP 600,000 - 900,000; Full time

Job summary

Concentrix Philippines is seeking a Clinical Appeals Specialist (PHRN) to review, process, and resolve appeals in line with NCQA and CMS guidelines. The role ensures timely, clinically sound determinations and supports documentation, member and provider communications, and quality targets of the payor program.

The position offers permanent remote work with government-mandated benefits and opportunities to grow in the US healthcare sector.

Qualifications

• Graduate of BS Nursing.
• Must possess an active PHRN License.
• At least 1 year of solid experience in InterQual or MCG (Milliman Care Guidelines).
• At least 2 years of bedside experience in high-acuity areas: ICU, CCU, ER.
• Must have a stable internet connection and a conducive home office setup for a Permanent WFH arrangement.

Responsibilities

• Apply InterQual or MCG to determine medical necessity of requested services.
• Coordinate with healthcare providers to ensure clinical documentation supports the level of care.
• Maintain high accuracy and productivity standards in a remote, fast-paced environment.

Skills

InterQual

MCG

Education

BS Nursing

Job description

Concentrix Philippines is seeking a Clinical Appeals Specialist (PHRN) to review, process, and resolve appeals in line with NCQA and CMS guidelines. The role ensures timely, clinically sound determinations and supports documentation, member and provider communications, and quality targets of the payor program.

The position offers permanent remote work with government-mandated benefits and opportunities to grow in the US healthcare sector.