Clinical Appeals Nurse

6 days ago

Ortigas Metro Manila, Philippines Connext Global Solutions Inc Full time ₱1,200,000 - ₱2,400,000 per year

Join Our Team as a Clinical Appeals Nurse

The Clinical Appeals Nurse audits medical records to support denial reviews, utilization reviews, and defense audits. The role requires strong clinical judgment, knowledge of InterQual and MCG criteria, and the ability to write detailed appeal letters while ensuring compliance with healthcare regulations.

Key Responsibilities:

• Audit medical records to identify or defend charges, including defense, patient, and biller-requested audits.


• Analyze records using InterQual, MCG, and payer-specific guidelines (Medicare, Medicaid, commercial) to assess medical necessity and appropriateness of care.


• Review and support appeals related to length of stay, managed care, RAC, and other specialized audits (e.g., CERT, ZPIC, SMRC).


• Obtain supporting documentation from physicians, hospitals, patients, or medical literature.


• Write detailed appeal letters addressing clinical and contractual issues.


• Manage multiple cases, prioritizing tasks and ensuring timely resolution.


• Record audit findings and documentation accurately in client systems.


• Use EMRs, billing systems, and quality platforms to complete assigned work efficiently.


• Comply with departmental policies and federal/state regulations, including HIPAA, FDCPA, and FCRA.


• Safeguard patient information in all documentation and communication.


• Maintain current knowledge of Medicare, Medicaid, and payer compliance standards.


• Participate in ongoing training to stay updated on clinical auditing and appeals best practices.

Qualifications:

• Experience in medical records review, claims processing, or clinical case management.


• Strong working knowledge of Medicare/Medicaid regulations.


• Proficient in electronic medical records and multiple system navigation.


• Strong analytical and critical thinking skills.


• Meticulous attention to detail and accuracy.


• Able to interpret complex clinical cases and guidelines.


• Proficient in Microsoft Office (Word, Excel, Outlook).


• Customer service-oriented with professionalism, flexibility, and a commitment to continuous learning and excellence.

Why Connext?

  • Competitive Compensation
  • Perfect Attendance Bonus
  • Company-Provided Equipment
  • 25% Night Differential Pay
  • Life and HMO Insurance Coverage
  • Good Company Culture

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