Clinical Appeal Nurse

4 days ago


Work from Home, Philippines Coronis Health LLC Full time ₱900,000 - ₱1,200,000 per year

Clinical Appeals Specialist is responsible in writing a compelling and effective appeal based on the clinical Documentation, payer-specific policies and is compliant to Federal and State policies. The Clinical Appeals Specialist is responsible for appeals and follow-up on clinical denials, providing appropriate denial information to be submitted to departments to ensure systems, processes and measures of effectiveness are created and implemented to resolve root cause issues and reduce/ eliminate denials. The Clinical Appeals Specialist ensures that appeals are submitted in a timely manner.

Responsibilities:

  • Performs medical record reviews concurrently and/or retrospectively and be able to determine why cases are denied and whether an appeal is required.
  • Able to review clinical denials in a timely manner and appropriately utilizing clinical criteria sets such as of InterQual criteria (Acute, Procedures, etc.). If clinical review does not meet IQ criteria, other pertinent clinical facts are utilized to support the appeal
  • Pertinent clinical facts include, but are not limited to, documentation preventing a safe transfer/discharge or documentation of medically necessary services denied for no authorization.
  • Able to write an effective and efficient appeal based on clinical documentation and payer specific policies and client-specific instructions.
  • Able to think critically and able to use clinical judgment in providing effective and well supported appeals.
  • Maintains thorough and current knowledge in clinical expertise and stay relevant in the fast changing trends in healthcare, reimbursement methodologies and utilization. Able demonstrate basic patient accounting knowledge i.e., UB04 claim form and Explanation of Benefits ("EOB") components, adjustments, credits, debits, balance due, patient liability, etc.
  • Able to read and understand medical abstract information from handwritten to type written medical record.
  • Demonstrates proficiency in utilization of electronic tools and competency in Microsoft Office.
  • Able to observe specific payer guidelines for appeal submission and ensures compliance to law and regulations.
  • Other tasks/functions that may be assigned by the company as per business requirement; these may change from time to time to reflect the changing requirement of your position and our business.

Qualifications:

  • Bachelor of Science in Nursing graduate
  • Must be Registered Nurse
  • Strong writing and grammatical skills
  • Above average written and verbal communication skills
  • Demonstrates proficiency in the application of medical necessity criteria.
  • Ability to conduct intensive research regarding State/Federal guidelines and other regulatory processes.
  • Excellent communication skills in verbal and professional letter writing skills.
  • Able to think critically.
  • MS Office proficient
  • Ability to multi-task.
  • Ability to work with minimal supervision and able to work under pressure within the given timeframe.
  • Self-motivated, customer-oriented and a strong team player
  • Must be a team player, and can also work independently, with minimal supervision

Job Type: Full-time

Work Location: Remote



  • Work from Home, Philippines Coronis Health LLC 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 clinical denial appeals and follow-up, providing appropriate denial information to departments to ensure...


  • Work from Home, Philippines Complete Care Management Services -ACO Full time ₱375,000 - ₱450,000 per year

    Job Title: Clinical ReviewerLocation: Philippines (Work from Home)Job Description:We are actively seeking a detail-oriented and experienced Clinical Reviewer to join our team in the Philippines. The Clinical Reviewer will play a crucial role in evaluating and ensuring the quality and compliance of clinical documentation. If you have a strong clinical...


  • Work from Home, Philippines Virtual Staffing Solutions Full time ₱1,200,000 - ₱2,400,000 per year

    DescriptionThe Emergency Triage Nurse plays a critical role in assessing and managing urgent patient concerns in a fast-paced aesthetics clinic. This nurse provides immediate clinical evaluation, prioritizes care needs, and ensures safe, timely intervention for post-procedure complications, adverse reactions, or unexpected symptoms.Key ResponsibilitiesRapid...


  • Work from Home, Philippines Cliniqon Full time

    Position: Clinical Care Coordinator (Licensed Practical Nurse/Registered Nurse)Job Summary:Looking for a dedicated Clinical Care Coordinator to oversee and optimize patient care. This role involves coordinating patient care plans, and ensuring compliance with healthcare regulations. The ideal candidate will have an experience in clinical coordination or...


  • Work from Home, Philippines Texas App Consulting Services Full time ₱384,000 - ₱480,000 per year

    Job Title: Remote Triage Support Nurse (Non-Clinical, Philippines-Based)Company: Texas APP Consulting Services LLCJob Type: Full-time, Remote (Work From Home)About the RoleTexas APP Consulting Services LLC is seeking experienced Filipino Registered Nurses to provide 24/7 non-clinical triage support to our U.S.-based clients. This role is fully remote,...


  • Work from Home, Philippines Seven Seven Global Services Inc Full time ₱600,000 - ₱800,000 per year

    Data assessment & schema finalization efforts for different markets.Create and maintain Schemas and Properties to fill in for the coding gaps across different clinical domains.Annotations - Analyse and interpret claims header level & line level descriptions and other documentation, categorize them into clinical domains (E.g., Procedures, radiology, Nursing...


  • Work from Home, Philippines Coronis Health LLC Full time ₱300,000 - ₱600,000 per year

    Clinical Denial Representative is responsible to review patient's medical claim when resolving edits for compliance (prior billing) and issues on rejections(rejected by the payor) in the physician side. Clinical Denial Representative must understand and comply with federal and state coding and billing regulation. The Clinical Denial Representative must...


  • Work from Home, Philippines Cliniqon Full time ₱420,000 - ₱540,000 per year

    Cliniqon is an organization that promotes a safe, inclusive work environment and prioritizes employees' well-being while creating a haven for clients and customers and their much-deserved experiences.Join Our Growing and Winning TeamCliniqon is hiring HOME HEALTH CLINICAL INTAKE COORDINATORSQualifications:Home Health background is a mustMust be a Registered...


  • Work from Home, Philippines Cliniqon LLC Full time

    Are you a skilled and compassionate RN looking to make a real impact, every single day? At CLINIQON, we're on a mission to elevate patient care and advocacy, and we're looking for a Nurse Case Manager who's ready to lead with both heart and expertise.If you thrive in a fast-paced environment, understand the ins and outs of Medicare, and are passionate about...


  • Work from Home, Philippines Cliniqon LLC Full time

    We are seeking an experienced and dedicated Clinical Coordinator (RN) to join our home health care team. This role is responsible for leading and supporting quality improvement efforts across the organization, ensuring clinical excellence, regulatory compliance, and positive patient outcomes. The Clinical Coordinator plays a key role in evaluating and...