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MicroSourcing

Clinical Denials & Appeals Nurse Specialist - IP & OP

MicroSourcing
Taguig, Philippines
3-5 Years
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Job Description

Discover your 100% YOU with MicroSourcing!

Position: Clinical Denials & Appeals Nurse Specialist - IP & OP
Location: Taguig
Work setup & shift: Onsite | Night shift

Why join MicroSourcing
Youu0027ll have:
  • Competitive Rewards: Enjoy above-market compensation, healthcare coverage on day one, plus one or more dependents, paid time-off with cash conversion, group life insurance, and performance bonuses
  • A Collaborative Spirit: Contribute to a positive and engaging work environment by participating in company-sponsored events and activities.
  • Work-Life Harmony: Enjoy the balance between work and life that suits you with flexible work arrangements.
  • Career Growth: Take advantage of opportunities for continuous learning and career advancement.
  • Inclusive Teamwork: Be part of a team that celebrates diversity and fosters an inclusive culture.
Your Role
As a Clinical Denials & Appeals Nurse Specialist - IP & OP, you will:
  • Review denied inpatient and outpatient claims and manage the appeals process accurately and within required timelines.
  • Evaluate denial reasons using payor information, payor policies, and clinical documentation to determine appropriate next steps.
  • Submit retro-authorizations in accordance with payor requirements in response to authorization-related denials.
  • Conduct medical necessity reviews based on denial root cause and prepare clinical documentation summaries to support appeals.
  • Write and submit formal written appeals using clinical documentation, third-party payor medical policies, and contract language track appeals through final resolution.
  • Document all actions taken and ensure timely follow-up with third-party payors to resolve denials and appeals.
  • Track the status, progress, and outcomes of denials and appeals.
  • Perform relevant research to support appeal preparation and remain informed on policy updates and best practices.
  • Execute internal and external correspondence accurately, clearly, and professionally while adhering to organizational policies.
  • Effectively manage communications via phone, email, instant messaging, and written correspondence with payors and internal stakeholders.
Tracking, Reporting, and Trends
  • Maintain data on types of claims denied and identify root causes.
  • Identify denial patterns, escalate findings to management, and provide sufficient details for follow-up or root cause resolution.
  • Collaborate with leadership to recommend process improvements aimed at reducing denials and accounts receivable.
  • Prepare, maintain, and submit reports as required.
Compliance and Continuous Improvement
  • Collaborate with team members to support service, process, and quality improvement initiatives.
  • Identify system improvement opportunities and contribute to testing system enhancements.
  • Maintain compliance with state and federal regulations, accreditation requirements, and Huron policies, including fraud and abuse, confidentiality, and HIPAA.
  • Maintain a thorough understanding of payer requirements, federal and state regulations, and explanations of benefits to identify billing compliance issues and payer discrepancies.
  • Participate in ongoing professional development to enhance job knowledge and performance.
  • Report identified compliance risks to appropriate leadership.
  • Perform other duties and responsibilities as assigned.
What You NeedNon-negotiables
  • At least 1 year of clinical appeal writing experience.
  • 3-5 years of acute care clinical experience in a hospital setting (Med/Surg or similar

More Info

Job Type:
Permanent Job
Industry:
IT/Computers - Software
Function:
Healthcare
Employment Type:
Full time

About Company

MicroSourcing

Founded in 2006, we pioneered a new way of offshoring. This model involves setting up an overseas division of your company and getting a local specialist to handle facilities, IT, labor laws, recruitment and HR, while you retain control over quality and productivity. Today, we&#8217&#x3B;re still one of the largest and most experienced offshoring providers in the Philippines, with 400+ active clients and 6,000+ employees. We operate within purpose-built, class-A facilities that are strategically located for access to Manila&#8217&#x3B;s most talented people. We&#8217&#x3B;re backed by our Australian parent company, Probe and we&#8217&#x3B;re ISO certified.

Job ID: 136336439

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Last Updated: 19-12-2025 08:43:12 AM
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