RN Utilization & Clinical Appeals Specialist

MedRisk; Mandaluyong; On-site; PHP 502,000 - 725,000; Full time

Job summary

MedRisk, based in the Philippines, seeks a Nurse Utilization and Clinical Advisor Services Analyst IV to apply clinical expertise and drive improvements in healthcare resource utilization, cost, and quality. You will analyze cases and claims, advise on care appropriateness, and coordinate with clients and clinical peer reviewers to support delivery standards.

You will collaborate with peers to resolve complex cases, price claims including drugs and supplies, and ensure compliance with company

Qualifications

• Bachelor’s degree in a relevant field.
• Active RN license in good standing.
• Experience in healthcare or medical services, preferably claims or case review.

Responsibilities

• Apply clinical judgment in adjudication of cases and claims.
• Review requests for denial reconsideration and appeals.
• Manually price and evaluate claims for care appropriateness and coverage.
• Provide input to clients per program policies and procedures.
• Collaborate with clinical peer reviewers to resolve cases and claims.
• Ensure compliance with company policies and standards.

Skills

Analytical skills

Policy interpretation

Plain-language communication

Education

Bachelor’s degree in a relevant field

Job description

MedRisk, based in the Philippines, seeks a Nurse Utilization and Clinical Advisor Services Analyst IV to apply clinical expertise and drive improvements in healthcare resource utilization, cost, and quality. You will analyze cases and claims, advise on care appropriateness, and coordinate with clients and clinical peer reviewers to support delivery standards.

You will collaborate with peers to resolve complex cases, price claims including drugs and supplies, and ensure compliance with company