Clinical Denials

Discover your 100% YOU with MicroSourcing
Position:
Clinical Denials & Appeals Nurse Specialist – IP & OP

Location:
Taguig

Work setup & shift:
Onsite | Night shift

Why join MicroSourcing?
You'll Have

• Competitive Rewards: Enjoy above-market compensation, healthcare coverage on day one, plus one or more dependents, 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
As a
Clinical Denials & Appeals Nurse Specialist – IP & OP
, you will:

• Review denied inpatient and outpatient claims and manage the appeals process accurately and within required timelines.
• Evaluate denial reasons using payor information, payor policies, and clinical documentation to determine appropriate next steps.
• Submit retro-authorizations in accordance with payor requirements in response to authorization-related denials.
• Conduct medical necessity reviews based on denial root cause and prepare clinical documentation summaries to support appeals.
• Write and submit formal written appeals using clinical documentation, third-party payor medical policies, and contract language; track appeals through final resolution.
• Document all actions taken and ensure timely follow-up with third-party payors to resolve denials and appeals.
• Track the status, progress, and outcomes of denials and appeals.
• Perform relevant research to support appeal preparation and remain informed on policy updates and best practices.
• Execute internal and external correspondence accurately, clearly, and professionally while adhering to organizational policies.
• Effectively manage communications via phone, email, instant messaging, and written correspondence with payors and internal stakeholders.

Tracking, Reporting, and Trends

• Maintain data on types of claims denied and identify root causes.
• Identify denial patterns, escalate findings to management, and provide sufficient details for follow-up or root cause resolution.
• Collaborate with leadership to recommend process improvements aimed at reducing denials and accounts receivable.
• Prepare, maintain, and submit reports as required.

Compliance and Continuous Improvement

• Collaborate with team members to support service, process, and quality improvement initiatives.
• Identify system improvement opportunities and contribute to testing system enhancements.
• Maintain compliance with state and federal regulations, accreditation requirements, and Huron policies, including fraud and abuse, confidentiality, and HIPAA.
• Maintain a thorough understanding of payer requirements, federal and state regulations, and explanations of benefits to identify billing compliance issues and payer discrepancies.
• Participate in ongoing professional development to enhance job knowledge and performance.
• Report identified compliance risks to appropriate leadership.
• Perform other duties and responsibilities as assigned.

What You Need
Non-negotiables

• At least 1 year of clinical appeal writing experience.
• 3–5 years of acute care clinical experience in a hospital setting (Med/Surg or similar); 2–3 years if ICU background.
• Bachelor of Science in Nursing.
• Active Registered Nurse (RN) license with PHRN or USRN credentials.
• Proficiency in InterQual or MCG clinical guidelines and broad knowledge of U.S. government programs and insurance regulations.
• Hands-on experience with hospital-based EMR systems such as Epic, Cerner, or Meditech.
• Strong verbal and written English communication skills with a minimum CEFR B2 level.

Preferred skills/expertise

• Master's degree or credential in business, healthcare, or a related field preferred.
• Certification in case management, clinical appeals, or clinical denials preferred.
• Proficiency in tools used for tracking denials and appeals, as well as the Microsoft Office Suite (Excel, Word, PowerPoint, Outlook, SharePoint).
• Strong attention to detail with excellent follow-up and follow-through skills.
• Ability to make complex decisions independently within scope of role.
• Demonstrated analytical and critical thinking capabilities.
• Experience working in a matrixed environment.
• Strong teamwork, integrity, and professionalism in interactions with internal and external stakeholders.
• Excellent written and verbal communication skills.

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.

At MicroSourcing, equality is not merely a slogan – it's our commitment. Our way of life. Here, we don't just accept your unique authentic self – we celebrate it, valuing every individual's contribution to our collective success and growth. Join us in celebrating YOU and your 100%

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