Clinical Appeals Nurse

2 weeks ago

Pasig, National Capital Region, Philippines Health Business Solutions Full time

Details

Join our dedicated team at HBiz where we strive to provide outstanding care and service excellence. We

are currently seeking a highly skilled Clinical Appeals Nurse to play a crucial role in managing medical

denials by providing clinical expertise in the appeals process. This position is ideal for those who excel in

analytical thinking and have a strong background in clinical practice and health information management.

Key Responsibilities:


• Review and analyze clinical documentation, utilization records, and insurance denial rationales to

formulate well-constructed appeal cases.


• Engage in the appeals process for denied claims, ensuring that all appeals are submitted in a timely

manner according to regulatory and insurer-specific requirements.


• Utilize clinical experience and knowledge in accordance with established Milliman or Interqual

guidelines to substantiate medical necessity and appropriate level of care.


• Collaborate with healthcare providers, case managers, and insurance companies to gather

additional information and advocate for proper patient services and reimbursement.


• Interpret and apply ICD-10 coding in the review of medical records to support appeal submissions.


• Maintain accurate and detailed records of all appeals processes, outcomes, and communications.


• Educate clinical staff on best practices, changes in payer requirements, and implications of clinical

documentation and coding standards.


• Active Registered Nurse (RN) license in the Philippines, US licensed preferred


• Minimum of two years of bedside clinical experience in a hospital setting.


• Proficiency with Milliman or Interqual clinical guidelines.


• Strong understanding of ICD-10 coding principles.


• Stay abreast of changes in healthcare regulations, payer policies, and clinical criteria guiding

medical necessity.

Qualifications:


• At least one year of experience in clinical appeals or utilization management.


• Bachelor's Degree in Nursing (BSN) preferred; minimum of an Associate Degree in Nursing (ADN)

required.


• Excellent written communication skills, with the ability to articulate complex clinical information in

a clear and professional manner for appeal justifications.


• Strong organizational skills and the ability to manage multiple cases simultaneously.

Desired Skills:


• Exceptional critical thinking and problem-solving skills.


• Demonstrated ability to work independently as well as part of a team.


• Commitment to ethical medical practices and compliance with all federal and state regulations.

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