We are looking for a Clinical Appeals Specialist PHRN who will review, process, and resolve appeal cases in alignment with NCQA, CMS standards, and client guidelines. In this role, you will ensure timely, accurate, and clinically sound appeal determinations while protecting member rights and supporting health plan obligations. You will also contribute to case documentation, member and provider communication, and overall program quality and compliance.
About the Role
Appeals Review and Assessment
- Review and evaluate appeal cases submitted by members, providers, or authorized representatives for Medicare Part C services.
- Assess the clinical appropriateness of initial decisions based on medical necessity, benefit coverage, and CMS guidelines.
Documentation and Case Processing
- Prepare clear, accurate, and compliant appeal determinations.
- Ensure all appeal cases are processed within required regulatory turnaround times.
- Partner with medical directors, case reviewers, and internal teams to gather necessary clinical information.
Communication and Quality Support
- Draft clear member and provider correspondence based on appeal outcomes.
- Participate in self-audits and continuous improvement activities to support quality goals.
- Safeguard confidentiality, data privacy, and HIPAA compliance.
- Escalate complex or high-risk cases when needed.
- Join training and calibration sessions to maintain strong regulatory and clinical knowledge.
Qualifications
- Active Philippine Registered Nurse license.
- At least one year of clinical nursing experience in a hospital, clinic, or managed care setting.
- Minimum of six months experience in clinical process outsourcing focused on appeals, utilization management, or related functions.
- Strong clinical judgment with the ability to interpret medical records and determine medical necessity.
- Understanding of healthcare insurance processes, appeals, grievances, and utilization management preferred.
- Excellent verbal and written communication skills, strong attention to detail, and solid case documentation skills.
- Ability to handle multiple cases while meeting strict deadlines.
- Proficiency in Microsoft Word, Excel, and Outlook.
- Willingness to work flexible schedules including US hours and holidays.
Nice to have
- Experience handling Medicare Part C or US-based appeals cases.
- Familiarity with CMS guidelines, NCQA standards, or URAC requirements.
- Experience using appeals management platforms such as VAM or Salesforce Health Cloud.
