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Job Summary: The Clinical Appeals Specialist (PHRN) is Responsible for the Review, Processing, and Resolution of Appeal(s) Case(s) in Compliance with NCQA and if Applicable, CMS Regulatory Standard(s) and Client Specific Guideline(s). The Role Ensures Timely and Clinically Sound Appeal Determination(s), Upholding Member Right(s) and Health Plan Obligation(s) Under Commercial and CMS Regulation(s). The Clinical Appeals Specialist also Supports Case Documentation, Member and Provider Communication(s), and Contributes to the Quality and Compliance Target(s) of the Payor Program.
Essential Duties and Responsibilities:
- Review and Assess Appeal(s) Case(s) Submitted by our Member(s), Provider(s), as well as Authorized Representative(s) for Medicare Part C Service(s), Evaluate the Clinical Appropriateness of Initial Determination(s) Based on Medical Necessity, Benefit Coverage, and CMS Guideline(s)
- Document Appeal Decision(s) Clearly, Accurately, and in Compliance with CMS Requirement(s) and Client Specific Protocol(s), Ensure Timely Processing of Appeal Case(s) within the Regulatory Turnaround Time(s) Set by CMS, Collaborate with Medical Director(s), Case Reviewer(s), and Internal Department(s) to Gather Required Clinical Information for Appeal Resolution
- Draft Clear and Compliant Member and Provider Correspondence Letter(s) Based on Appeal Outcome(s), Support the Appeals Quality Program by Participating in Self-Audit(s) and Implementing Feedback for Continuous Improvement, Uphold High Level(s) of Data Privacy, Confidentiality, and HIPAA Compliance Standard(s), Participate in Ongoing Training, Calibration, and Performance Discussion(s) to Maintain Clinical and Regulatory Knowledge, Escalate Complex or High-Risk Case(s) to Medical Director(s) or Appeals Leadership as Required
Minimum Hiring Qualifications:
- Active Philippine Registered Nurse (PHRN) with License Required - 1 Year Minimum of Clinical Nursing Experience (Hospital, Clinic, or Managed Care Setting) with 6 Month(s) Minimum of Clinical Process Outsourcing Experience and Background Handling Clinical Role(s) Focusing on Clinical Appeals and Utilization Management and Other Related Function(s)
- Strong Clinical Knowledge Particularly in Medical Necessity Review and Interpretation of Clinical Documentation(s), Good Knowledge and Understanding of Different Healthcare Insurance Process(es), Appeals, Grievances, and Utilization Management is Preferred
- Demonstrates Excellent Verbal and Written Communication Skills, Strong Attention to Detail and Case Documentation Practice(s), Ability to Manage Multiple Case(s) and Meet Regulatory Turnaround Time(s) Under Pressure, Proficient in Basic Microsoft Office Application(s) such as Word, Excel, and Outlook, Willing to Work on Flexible Schedule(s) Including US Hour(s) and Holiday(s)
- Preferred Qualification(s): Experience Handling Medicare Part C or US-Based Appeals Case(s), Familiarity with CMS Guideline(s), NCQA Standard(s), or URAC Regulation(s), Experience in Using Appeals Management Platform(s) (VAM and Salesforce Health Cloud)
- Candidate(s) should be Available to Start on December 9, 2025 (Tuesday) - Successful Candidate(s) will Get a 50K Signing Bonus! (Terms and Conditions Apply)
Get Hired and Enjoy the Following:
- Interact/Collaborate and Learn from Industry Experts
- Multiple Opportunities for Learning and Development
- Enjoy a Fun - and Competitive Working Environment
Work Location: Tera Tower, Bridgetowne, Quezon City
