PHRN/USRN Denial Specialist

Work Setup: On-site (Initially will be assigned to BGC, Taguig, and will then be transferred to Bridgetown, Quezon City within six (6) months)

Work Schedule: Night Shift

SOB: PHP 100,000* T&Cs apply

With a 1-year employment bond

REQUIRED QUALIFICATIONS:

• Active USRN or PHRN license
• 2–3 years of experience in Denials Management or Utilization Management (UM)/Utilization Review (UR), and/or
• 2–3 years of clinical bedside experience (must be indicated on the CV)
• Provider-side experience is required
• Experience in Clinical Review
• Exposure to DRG downgrades and post-pay audits
• Knowledge of coding denials, inpatient coding, and DRG-related claims
• Working knowledge of NCCI indicators
• Experience navigating healthcare payer portals for claims, denials, or appeals.
• Can start on October 1, 2026

Preferred Qualifications

• Inpatient (IP) Coding certification: CIC, CPC, and CCS
• Exposure to Clinical Documentation Integrity (CDI)
• RHIT certification, particularly with experience handling DRG downgrade denials or post-pay audits

Job Overview: The Clinical Denials Specialist reviews denied healthcare claims to identify clinical and coding issues, assess documentation, and support accurate reimbursement. The role collaborates with providers and internal teams to evaluate cases, identify gaps, and address denial trends to help prevent future denials. Strong clinical, inpatient coding, analytical, and decision-making skills are essential.

• Denial Review & Appeals
• Denial Trend Analysis & Process Improvement
• Clinical & Regulatory Knowledge
• Communication & Collaboration