Clinical Appeals and Denials

1 week ago

Pasig, Philippines Swift-up Full time

The PH Registered Nurse (PHRN) collaborates with healthcare providers and members to promote quality outcomes, optimize member benefits, and ensure the effective use of healthcare resources. This role ensures that care provided is medically appropriate, high-quality, and cost-effective by reviewing medical necessity for inpatient admissions, outpatient services, surgical and diagnostic procedures, and treatment settings in accordance with applicable medical policies and clinical guidelines. Essential Duties and Responsibilities: Accurately interpret member benefits and managed care products, guiding members to appropriate providers, programs, or community resources. Work with Medical Directors to evaluate the appropriateness of care and ensure accuracy in medical claims. Conduct pre-certification, continued stay reviews, care coordination, and discharge planning to ensure compliance with medical policies, member eligibility, benefits, and contracts. Support accreditation efforts by understanding and applying accrediting and regulatory standards. Ensure member access to necessary and quality healthcare in a cost-effective setting. Collaborate with Clinical Reviewers and Medical Directors to maintain medically appropriate, high-quality, and cost-effective care. Work closely with providers to identify member needs early and plan proactive discharge and care transitions. Facilitate smooth member transitions across the healthcare continuum and refer care plans to Clinical Reviewers as required (note: PHRNs do not issue non-certifications). Minimum Hiring Qualifications: Education: Bachelor’s Degree in a related field. Experience: Minimum of 2 years BPO clinical experience (preferably in Utilization Management, Appeals Management, or Denials). License: Current, active, and unrestricted license to practice as a Registered Nurse (PHRN). Skills: Strong oral, written, and interpersonal communication; analytical, facilitation, and problem-solving skills. #J-18808-Ljbffr

  • Clinical Appeals and Denials PHRN

    3 days ago

    Pasig, National Capital Region, Philippines Swift-up Full time ₱900,000 - ₱1,200,000 per year

    The PH Registered Nurse (PHRN) collaborates with healthcare providers and members to promote quality outcomes, optimize member benefits, and ensure the effective use of healthcare resources. This role ensures that care provided is medically appropriate, high-quality, and cost-effective by reviewing medical necessity for inpatient admissions, outpatient...

  • Clinical Appeals Nurse Writer

    7 days ago

    Pasig, National Capital Region, Philippines Coronis Health Full time ₱1,200,000 - ₱2,400,000 per year

    JOB SUMMARY:The Clinical Appeals Nurse is responsible for creating a convincing and effective appeal based on clinical documentation, payer-specific standards, and compliance with federal and state policies. The Clinical Appeals Nurse is responsible for handling clinical denial appeals and follow-up, providing relevant denial information to departments to...

  • Clinical Denials and Appeals PHRN

    3 days ago

    Pasig Central Post Office P, Philippines Swift-up Full time ₱600,000 per year

    The PH Registered Nurse (PHRN) collaborates with healthcare providers and members to promote quality outcomes, optimize member benefits, and ensure the effective use of healthcare resources. This role ensures that care provided is medically appropriate, high-quality, and cost-effective by reviewing medical necessity for inpatient admissions, outpatient...

  • USRN – Denials

    1 week ago

    Pasig, National Capital Region, Philippines Global Group Innovative Services Full time ₱1,080,000 - ₱1,140,000 per year

    Qualifications:Active USRN license in any U.S. stateMinimum 2 years of hospital or bedside experience in an acute care setting (Med/Surg, Ortho, ER)Experience using InterQualStrong analytical and clinical judgment skillsKey Responsibilities:Review and analyze denied inpatient claims and determine reasons for denial following IP DRG coding guidelinesPrepare...

  • Registered Nurse

    3 days ago

    Pasig, National Capital Region, Philippines Find HR Full time ₱35,000 - ₱45,000 per year

    Employment Type: PermanentWork Setup: Onsite – Graveyard ShiftingLocation: Ortigas, Pasig CityStart Date: ASAPRole OverviewWe are looking for an active PHRN (Philippine Registered Nurse) with claims & denials and appeals / utilization review (UR) experience to join our healthcare BPO team. In this role, you will leverage your clinical background and...

  • Appeal Writer

    5 days ago

    Pasig, National Capital Region, Philippines Med-Metrix Full time ₱250,000 - ₱500,000 per year

    Join our dynamic team and make a meaningful impact in the healthcare industry. Enjoy competitive benefits upon hire, ongoing professional development, and the satisfaction of helping others every day. Take the next step in your career with Med-MetrixExperience these exceptional benefits when you join Med-Metrix8-Hour ShiftsDay 1 HMO with 2 of your dependents...

  • Appeal Writer

    2 weeks ago

    Pasig, Philippines Med Metrix Full time

    Job Description Posted Sunday, February 16, 2025 at 4:00 PM Join our dynamic team and make a meaningful impact in the healthcare industry. Enjoy competitive benefits upon hire, ongoing professional development, and the satisfaction of helping others every day. Take the next step in your career with Med-Metrix! Experience these exceptional benefits when you...

  • Appeal Writer

    2 days ago

    Pasig, Philippines Med-Metrix, LLC Full time

    Job Description Posted Sunday, November 2, 2025 at 4:00 AM Join our dynamic team and make a meaningful impact in the healthcare industry. Enjoy competitive benefits upon hire, ongoing professional development, and the satisfaction of helping others every day. Take the next step in your career with Med-Metrix! Experience these exceptional benefits when you...

  • Appeal Writer

    8 hours ago

    Pasig, Philippines Med-Metrix Full time

    Med-Metrix Pasig, National Capital Region, Philippines Join our dynamic team and make a meaningful impact in the healthcare industry. Enjoy competitive benefits upon hire, ongoing professional development, and the satisfaction of helping others every day. Take the next step in your career with Med-Metrix! Experience these exceptional benefits when you join...

  • Clinical Training Manager

    1 day ago

    Pasig, National Capital Region, Philippines Omega Healthcare Management Services Inc. Full time ₱1,200,000 - ₱2,400,000 per year

    PRIMARY DUTIES AND RESPONSIBILITIES:· Project- manages the smooth roll out of courses at the location.· Work on areas identified for improvement based on feedback received about the quality of the training programs.· To ensure confidentiality, integrity and availability of all data dealt in course of work· To ensure the completion of compliance awareness...