PHRN for Non-Voice

41 minutes ago

Pasay, National Capital Region, Philippines Access Healthcare Services Manila, Inc. Full time ₱900,000 - ₱1,200,000 per year

Access Healthcare is looking for a Utilization and Clinical Denials Nurse to join our growing clinical account. The ideal candidate is a Licensed Philippines Nurse with at least one (1) year of hospital bedside experience and a strong understanding of utilization review, clinical documentation, and denial management in a BPO set-up. This role involves reviewing medical cases, ensuring compliance with payer requirements, and assisting in the appeals process for denied claims.

Key Responsibilities:

  • Conduct utilization reviews to assess medical necessity, appropriateness, and efficiency of healthcare services.
  • Analyze clinical denials and collaborate with internal teams to determine appeal strategies.
  • Review medical records and ensure compliance with insurance policies and industry guidelines.
  • Assist in preparing clinical appeals and reconsideration letters for denied claims.
  • Provide medical rationale and justifications based on clinical evidence and payer guidelines.
  • Communicate with insurance providers, physicians, and other healthcare professionals regarding authorization approvals or denials.
  • Stay updated on healthcare policies, medical guidelines, and payer requirements to optimize claims processing.
  • Ensure compliance with HIPAA regulations, data privacy laws, and company protocols.

Qualifications:

  • Must be a Licensed Philippines Nurse (PH RN).
  • At least one (1) year of hospital bedside experience (ICU, ER, Med-Surgery, or similar preferred).
  • Experience in utilization review, clinical denials management, or medical claims processing is an advantage.
  • Strong understanding of insurance policies, medical necessity criteria, and appeal processes.
  • Excellent critical thinking, analytical, and problem-solving skills.
  • Effective written and verbal communication skills.
  • Proficiency in medical terminology, coding (ICD-10, CPT), and healthcare documentation is a plus.
  • Ability to work in a fast-paced BPO environment with shifting schedules.

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