Urgent Opening! Temporary WAH! PHRN! Clinical Appeals Specialist

Concentrix Philippines; Quezon City; Vor Ort; PHP 550.000 - 850.000; Vollzeit

Benefits dieser Stelle

Learning and development opportunities

Collaborative team environment

Dynamic work culture

Zusammenfassung

Concentrix Philippines seeks an experienced Clinical Appeals Specialist (PHRN) to review and resolve CMS/regulatory-compliant appeal cases. You will ensure timely determinations and accurate documentation, while communicating with members and providers.

You will bring 2+ years of clinical nursing experience and 1 year in clinical process outsourcing, with Interqual/MCG knowledge, and exposure to insurance processes. Flexible US hour availability is required.

Qualifikationen

• Active Philippine Registered Nurse (PHRN) with license.
• Minimum 2 years clinical nursing experience in hospital, clinic, or managed care setting.
• Minimum 1 year of clinical process outsourcing experience focusing on clinical appeals and utilization management (Interqual and MCG).
• Strong clinical knowledge in medical necessity review and documentation interpretation.
• Good knowledge of 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 under regulatory turnaround times.
• Proficient in Word, Excel, and Outlook.
• Willing to work flexible schedules including US hours and holidays.

Aufgaben

• Review and assess appeal cases submitted by members, providers, and authorized representatives for Medicare Part C services.
• Evaluate clinical appropriateness of determinations based on medical necessity and CMS guidelines.
• Document appeal decisions clearly in CMS-compliant format.
• Ensure timely processing of appeals within CMS turnaround times.
• Collaborate with medical directors and internal teams to gather required information for resolution.
• Draft compliant member/provider correspondence based on outcomes.
• Support quality program through self-audits and process feedback.
• Uphold confidentiality, data privacy, and HIPAA standards.
• Escalate complex or high-risk cases to leadership when needed.
• Participate in training and calibration to maintain regulatory knowledge.

Kenntnisse

2+ years clinical nursing experience

1 year clinical process outsourcing

Interqual and MCG knowledge

MS Office (Word/Excel/Outlook)

Ausbildung

Philippine Nursing License (PHRN)

Tools

MS Office

Jobbeschreibung

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 2 years of clinical nursing experience in hospital, clinic, or managed care setting

• Minimum 1 year of clinical process outsourcing experience with background handling clinical roles focusing on clinical appeals and utilization management (Interqual and MCG)

• 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.