Work From Home Opportunity for PHRNs | Clinical Appeals Specialist

Concentrix Philippines; Quezon City; Remote; PHP 480,000 - 720,000; 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 standards. You will ensure timely, clinically sound determinations and support case documentation for payor programs.

The role requires a BS Nursing with an active PHRN license, 1 year with InterQual or MCG, and 2 years bedside ICU/CCU/ER experience. Remote work setup is required.

Qualifications

• BS Nursing degree and active PHRN license.
• Minimum 1 year experience with InterQual or MCG.
• Minimum 2 years bedside experience in ICU/CCU/ER.
• Must have stable internet and home office setup for WFH.

Responsibilities

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

Skills

InterQual

MCG

Remote work readiness

Education

BS Nursing

PHRN License

Job description

Are you ready to POWER UP your skills? Take the leap and join Concentrix's League of TOP-NOTCH TALENTS! Prepare for an Extra-Ordinary Journey where you not only Collaborate with Industry Champions but also immerse yourself in an Innovative Workplace filled with Laughter, Continuous Learning, and Limitless Opportunities. Join the Leading Global Provider of CX and Tech Services and seize this moment to #JoinConcentrix!

Job Summary

The clinical appeals specialist (PHRN) is responsible for the review, processing, and resolution of appeals cases in compliance with NCQA and, if applicable, CMS regulatory standards and client specific guideline. The role ensures timely and clinically sound appeal determination, upholding member rights and health plan obligations under commercial and CMS regulations. The clinical appeals specialist also supports case documentation, member and provider communications, and contributes to the quality and compliance targets of the payor program.

Essential Duties and Responsibilities

• Apply InterQual or MCG (Milliman Care Guidelines) to determine the 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.

Minimum Qualifications

• Education: Graduate of BS Nursing.
• License: Must possess an active PHRN License.
• CPO Experience: At least 1 year of solid experience in InterQual or MCG (Milliman Care Guidelines).
• Clinical Experience: At least 2 years of bedside experience in high-acuity areas:
  • ICU (Intensive Care Unit)
  • CCU (Critical Care Unit)
  • ER (Emergency Room)
• Tech Requirements: Must have a stable internet connection and a conducive home office setup for a WFH arrangement.

Why Join Us?

• Remote Work setup.
• Government-mandated benefits and HMO.
• Opportunities for career growth in the US Healthcare industry.