Clinical Appeals and Denials PHRN

6 hours ago

Pasig, National Capital Region, Philippines Swift-up Full time ₱900,000 - ₱1,200,000 per year

The PH Registered Nurse (PHRN) collaborates with healthcare providers and members to promote quality outcomes, optimize member benefits, and ensure the effective use of healthcare resources. This role ensures that care provided is medically appropriate, high-quality, and cost-effective by reviewing medical necessity for inpatient admissions, outpatient services, surgical and diagnostic procedures, and treatment settings in accordance with applicable medical policies and clinical guidelines.


Essential Duties and Responsibilities:
  • Accurately interpret member benefits and managed care products, guiding members to appropriate providers, programs, or community resources.
  • Work with Medical Directors to evaluate the appropriateness of care and ensure accuracy in medical claims.
  • Conduct pre-certification, continued stay reviews, care coordination, and discharge planning to ensure compliance with medical policies, member eligibility, benefits, and contracts.
  • Support accreditation efforts by understanding and applying accrediting and regulatory standards.
  • Ensure member access to necessary and quality healthcare in a cost-effective setting.
  • Collaborate with Clinical Reviewers and Medical Directors to maintain medically appropriate, high-quality, and cost-effective care.
  • Work closely with providers to identify member needs early and plan proactive discharge and care transitions.
  • Facilitate smooth member transitions across the healthcare continuum and refer care plans to Clinical Reviewers as required (note: PHRNs do not issue non-certifications).

Minimum Hiring Qualifications:
  • Education: Bachelor's Degree in a related field.
  • Experience: Minimum of 2 years BPO clinical experience (preferably in Utilization Management, Appeals Management, or Denials).
  • License: Current, active, and unrestricted license to practice as a Registered Nurse (PHRN).
  • Skills: Strong oral, written, and interpersonal communication; analytical, facilitation, and problem-solving skills.

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