Urgent Opening! PHRN! Clinical Appeals Specialist

The Clinical Appeals Specialist (PHRN) is responsible for the review, processing, and resolution of appeal cases in compliance with NCQA and if applicable, CMS regulatory standards and client specific guidelines. You will ensure timely and clinically sound appeal determinations, upholding member rights and health plan obligations under commercial and CMS regulations. You will also support case documentation, member and provider communications, and contribute to the quality and compliance targets of the payor program.

Key responsibilities

Review and assess appeal cases submitted by members, providers, and authorized representatives for Medicare Part C services

Evaluate the clinical appropriateness of initial determinations based on medical necessity, benefit coverage, and guidelines determined and implemented by CMSDocument appeal decisions clearly, accurately, and in compliance with CMS requirements and client specific protocols

Ensure timely processing of appeal cases within the regulatory turnaround times set by CMSCollaborate with medical directors, case reviewers, and internal departments to gather required clinical information for appeal resolution

• Draft clear and compliant member and/or provider correspondence letters based on appeal outcomes
• Support the appeals quality program by participating in self-audits and implementing feedback for continuous improvement
• Uphold high levels of confidentiality, data privacy, and HIPAA compliance standards
• Escalate complex or high-risk cases to medical directors or appeals leadership as required
• Participate in training, calibration, and performance discussions to maintain clinical and regulatory knowledge

About you

• Active Philippine Registered Nurse (PHRN) with license required
• Minimum 2 years of clinical nursing experience in hospital, clinic, or managed care setting

Minimum 1 year of clinical process outsourcing experience with background handling clinical roles focusing on clinical appeals and utilization management (Interqual and MCG)Strong clinical knowledge particularly in medical necessity review and interpretation of clinical documentation

• Good knowledge and understanding of different healthcare insurance processes, appeals, grievances, and utilization management (preferred)
• Excellent verbal and written communication skills
• Strong attention to detail and case documentation practices
• Able to manage multiple cases while meeting regulatory turnaround times under pressure
• Proficient in basic Microsoft Office applications such as Word, Excel, and Outlook
• Willing to work on flexible

work schedule

s including US hours and holidays

Benefits

• Interact and collaborate with industry experts
• Multiple opportunities for learning and development
• Fun and competitive working environment

About us

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