Step into a high-impact role where your clinical expertise goes beyond bedside care. As a Clinical Appeals Nurse, you'll play a crucial role in advocating for accurate healthcare decisions by reviewing medical records, supporting denial appeals, and ensuring fair outcomes for hospital clients. This role combines clinical knowledge, analytical thinking, and strong communication skills to resolve complex cases and drive quality results.
What You'll Do
- Conduct in-depth audits of medical records to support denial reviews, defense audits, and billing validations
- Evaluate cases using industry standards such as InterQual and MCG, along with payer guidelines (Medicare, Medicaid, and commercial insurers)
- Handle specialized appeals including avoidable LOS, RAC audits, CERT, ZPIC, and SMRC reviews
- Collaborate with physicians, hospitals, and other stakeholders to gather necessary documentation
- Craft well-structured, compelling appeal letters addressing both clinical and contractual concerns
- Manage multiple cases simultaneously while ensuring accuracy, efficiency, and timely resolution
- Navigate EMRs, billing platforms, and other healthcare systems with confidence
- Maintain strict compliance with healthcare regulations, including HIPAA, FDCPA, and FCRA
- Stay updated on evolving regulations, standards, and best practices in clinical auditing and appeals
What We're Looking For
- Strong experience in medical record review, claims processing, or clinical case management
- Background in Medicare/Medicaid regulations
- Hands-on experience with EMRs and multiple system navigation
- Proficiency in Microsoft Office (Word, Excel, Outlook)
- Bedside nursing experience is a must
- Exceptional attention to detail and accuracy
- Strong analytical and critical thinking skills
- Excellent written and verbal English communication skills
- Customer-focused mindset with professionalism and adaptability
Screening Criteria
- At least 3 years of clinical experience (or equivalent in auditing, utilization review, denials, or Medicare appeals)
- Minimum 1 year of clinical appeals writing experience
- Stable employment history
- Willing to work onsite in Ortigas
This is your opportunity to transition into a specialized, high-value role where your clinical expertise directly impacts healthcare outcomes, compliance, and financial accuracy—while continuously growing your skills in a dynamic and rewarding environment.
