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Clinical Denials and Appeals Manager

23 hours ago

Taguig, National Capital Region, Philippines MicroSourcing Full time

Discover your 100% YOU with MicroSourcing
Position:
Clinical Denials and Appeals Manager

Location:
Taguig

Work setup & shift:
Onsite | Night shift

Sign-on bonus: 100,000*
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.

Our client,
Huron
, is a global professional services firm that collaborates with clients to put possibilities into practice by creating sound strategies, optimizing operations, accelerating digital transformation, and empowering businesses and their people to own their future. By embracing diverse perspectives, encouraging new ideas, and challenging the status quo, Huron creates sustainable results for the organizations they serve.

Your Role
The Clinical Denials and Appeals Manager is responsible for the day-to-day operations and oversight of initial and concurrent clinical reviews in addition to Clinical Denials processes. This role ensures accuracy in utilization management up to and including the review of the claims denied. This manager ensures the team carries out the appeals process appropriately and in a timely manner. This leader ensures adherence to regulatory guidelines and payer requirements and supports optimal reimbursement through the appeals process.

You Will
Operational Oversight

  • Manage team to achieve specific goals by overseeing daily activities, assigning tasks, and providing guidance and motivation.
  • Key responsibilities include setting objectives, ensuring efficient task completion, monitoring performance, solving problems, and facilitating communication between the team and upper management.
  • Effective team managers possess strong leadership, communication, and problem-solving skills.

Quality & Compliance

  • Address Utilization management and Clinical Denials, and partner with billing and A/R teams to identify root causes.
  • Stay current with Utilization Management and Clinical Denials updates and disseminate guidance to staff.
  • Ensure Utilization Management, Clinical Denials & Appeals policies & procedures are current and reflect the most compliant/accepted practices for medical coding.

Collaboration & Support

  • Effectively communicate the team's performance in Operations Meeting, including reporting on KPIs, progress, and opportunity areas.
  • Work closely with HIM, Revenue Integrity, Coding, Billing, and Clinical departments to ensure clean claim generation.
  • Support coding accuracy through collaboration with revenue integrity.
  • Coordinate with IT on encoder, EHR, Utilization management, and Clinical Denials & Appeals system optimization.

Education & Training

  • Provide guidance on Utilization Management and Clinical Denials & Appeals education strategies, including on clinical denials updates, documentation changes, and audit findings.
  • Mentor Utilization Management/Clinical Denials & Appeals supervisors, trainers/QA specialists, or RN specialists to support succession planning and career development.

Coordinating with Healthcare Providers

  • Work closely with physicians, nurses, and other healthcare professionals to ensure timely and accurate documentation that reflects the care provided to patients. Obtain clarification as appropriate.

Other duties and responsibilities as assigned.
What You Need
Non-negotiables

  • Management Experience: At least 2 years of utilization management and/or clinical denials and appeals management experience.
  • Clinical Experience: Minimum of 3-5 years acute care clinical experience in a hospital setting (Med/Surg, or similar preferred); 2-3 years of ICU experience.
  • Education: Bachelor of Science in Nursing.
  • Licensure: Must be a Registered Nurse with an active PHRN or USRN license.
  • RCM Knowledge: Proficiency in using InterQual or MCG clinical guidelines. Broad Knowledge of U.S. Government Programs and Insurance Regulations
  • Software Knowledge: Proficiency with hospital-based electronic medical records (EMR) such as Epic, Cerner, or Meditech.
  • Excellent verbal and written English communication skills and customer service skills (CEFR level of at least B2 for both verbal and written)

Preferred Skills/expertise

  • Education: Master's degree or credential in business, healthcare, or related field preferred
  • Credential/Certification: Case management, clinical appeals, or clinical denials certification (ACMA) is preferred.
  • Software Knowledge: Proficiency with using computer programs for tracking authorization, and/or denials and appeals. Proficiency with Microsoft Office suite (Excel, Word, PowerPoint, Outlook, SharePoint).

Soft Skills

  • Proven leadership experience managing teams, including coaching, mentoring, and performance management.
  • Ability to independently lead teams, set project direction, develop key deliverables, escalate risks, and influence stakeholders.
  • Strong analytical and critical thinking skills.
  • Experience in a matrixed environment
  • Excellent written and verbal communication skills; ability to create impactful presentations
  • Ability to pay close attention to details; strong follow-up and follow-through skills
  • Regularly makes complex decisions within the scope of the position, and is comfortable working independently
  • Requires the use of independent judgment, discretion and decision-making abilities
  • Demonstrates teamwork and integrity in all work-related activities

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. We provide space for everyone, embracing different perspectives, and making room for opportunities for each individual to thrive.

At MicroSourcing, equality is not merely a slogan - it's our commitment and 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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