Clinical Review Nurse
2 weeks ago
Clinical Review Nurse – Denials & Appeals Position: Clinical Review Nurse – Denials & Appeals Location: Taguig Work setup & shift: Onsite | Night shift Why join MicroSourcing? Competitive Rewards: Enjoy above‑market compensation, healthcare coverage on day one (for you and at least one dependent), 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 Review denied claims, evaluate denial reasons, and carry out the appeals process in a timely and accurate manner. Submit retro‑authorizations and conduct medical necessity reviews based on denial root causes. Prepare and submit compelling written appeals based on clinical documentation, payer policies, and contract language. Track and document all denial and appeal activities, ensuring timely follow‑up and resolution. Identify denial trends, elevate recurring issues, and recommend process improvements to reduce accounts receivable (A/R). Collaborate with management to enhance processes, ensure compliance with regulations, and maintain accurate reporting. Stay informed of federal/state regulations, payer requirements, and clinical guideline updates (InterQual, MCG). Participate in continuous improvement initiatives and professional development activities. What You Need Non‑negotiables At least 1 year of clinical appeal writing experience. Minimum 3‑5 years of acute care clinical experience in a hospital setting (Med/Surg or similar); 2‑3 years if ICU experience. Bachelor of Science in Nursing. Registered Nurse (PHRN or USRN) with active license. Proficiency with InterQual or MCG clinical guidelines. Familiarity with U.S. government programs and insurance regulations. Experience using electronic medical records (EMR) such as Epic, Cerner, or Meditech. Preferred skills/expertise Master's degree or credential in business, healthcare, or related field. Certification in case management, clinical appeals, or clinical denials. Experience using systems for tracking denials and appeals. Proficiency in Microsoft Office Suite (Excel, Word, PowerPoint, Outlook, SharePoint). Excellent analytical, critical thinking, and communication skills. Strong attention to detail and ability to make sound decisions independently. Experience working in a matrixed environment. About MicroSourcing With over 9,000 professionals across 13 delivery centers, MicroSourcing is the pioneer and largest offshore provider of managed services in the Philippines. Our commitment to 100% YOU MicroSourcing firmly believes that our company's strength lies in our people's diversity and talent. We are proud to foster an inclusive culture that embraces individuals of all races, genders, ethnicities, abilities, and backgrounds, provides space for everyone, embraces different perspectives, and makes room for opportunities for each individual to thrive. Equality is not merely a slogan – it is our commitment. Join us in celebrating YOU and your 100% For more information, visit Terms & conditions apply. #J-18808-Ljbffr
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