PHRN Appeals Specialist

1 week ago

Manila, National Capital Region, Philippines Sysgen RPO, Inc. Full time
Job Summary

The PHRN Appeals Specialist is responsible for reviewing, evaluating, and processing medical appeals in accordance with client and regulatory guidelines. The role requires strong clinical knowledge, analytical skills, and the ability to communicate effectively with members and healthcare professionals.

Qualifications
  • Must have experience in handling appeals
  • Active RN license (PHRN)
  • Minimum 1 year bedside experience and 6 months CPO/BPO experience
  • Solid understanding of clinical procedures and medical documentation
  • Strong attention to detail and decision-making skills
  • Ability to work onsite and collaborate with a US-based client
Key Responsibilities
  • Review and evaluate medical appeals and clinical documents
  • Ensure decisions comply with regulatory and client requirements
  • Coordinate with providers, members, and internal teams for case clarification
  • Maintain accurate documentation of case decisions
  • Meet department turnaround times and quality standards

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