PHRN – Appeals

3 hours ago

Quezon City, National Capital Region, Philippines StaffLink Express Full time ₱40,000 - ₱60,000 per year

Job Title: PHRN – Appeals & Denials Nurse

Work Setup:
On-site, Bridgetowne, Quezon City

Shift:
Night Shift

Salary Package:
PHP 50,762 (Basic: 43,762 + 7,000 Allowance)

Signing Bonus:
Released on first payout for candidates who can join on
December 9
or immediately

Target Start Date:
December 9, 2025

Headcount:
12

Role Summary

The PHRN Appeals & Denials Nurse is responsible for reviewing clinical documentation, conducting medical necessity evaluations, and resolving appeals and denials cases in alignment with regulatory, payer, and clinical standards. This role requires strong clinical judgment, analytical skills, and familiarity with healthcare insurance processes to ensure accurate and compliant case resolutions.

Qualifications (Must-Have)

  • Active
    Philippine Registered Nurse (PHRN)
    license.
  • Minimum
    1 year of clinical nursing experience
    (Hospital, Clinic, or Managed Care Setting).
  • At least
    6 months of Clinical Process Outsourcing (CPO/BPO) experience
    handling clinical functions such as:
  • Appeals & Denials
  • Utilization Management
  • Medical Necessity Review
  • Other related clinical operations
  • Strong understanding of
    clinical documentation interpretation
    and medical necessity criteria.
  • Knowledge of
    healthcare insurance processes
    , including appeals, grievances, and utilization management.
  • Excellent
    verbal and written communication
    , with strong attention to detail and documentation practices.
  • Ability to handle multiple cases and meet required
    turnaround times
    in a fast-paced environment.
  • Proficient in
    MS Office
    (Word, Excel, Outlook).
  • Willing to work flexible schedules, including
    US Hours and US Holidays
    .

Preferred Qualifications

  • Experience handling
    Medicare Part C
    or US-based appeals cases.
  • Familiarity with
    CMS Guidelines
    ,
    NCQA Standards
    , or
    URAC Regulations
    .
  • Experience using
    Appeals Management Platforms
    or
    Salesforce Health Cloud
    .
  • InterQual
    experience is a strong plus.

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