CNX
Clinical BP_2026
Philippines · Work style not stated · Full time
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About the role
Description from the employer’s posting. Check the employer’s page for the current version.
- EmployerCNX
- LocationPhilippines
- Work styleWork style not stated
- Employment typeFull time
- Employer posted
Job Title:
Clinical BP_2026
Job Description
We are seeking a highly skilled and detail-oriented Appeals PHRN Specialist to support our expanding Medicare line of business. The ideal candidate will have a strong background in Utilization Management (UM), appeals processing, and case validation, with hands-on experience in Medicare UM or Appeals. This role will be critical in ensuring high-quality clinical review, thorough case investigation, and timely resolution of appeal cases in accordance with CMS guidelines.
Appeals Review & Case Handling:
○ Review, evaluate, and process appeal requests for Medicare members in compliance with CMS regulations and organizational protocols.
○ Conduct thorough case validation and clinical review using sound judgment and medical necessity criteria.
Collaboration:
○ Collaborate with onshore payer nurses and Independent Review Organizations (IROs) to collect and verify necessary documentation for appeal resolution.
○ Escalate complex cases as needed, providing detailed summaries and clinical insights.
Show full description
Documentation & Communication:
○ Provide clear documentation and clinical rationales for approval or denial decisions.
○ Maintain accurate records of all case activities and communicate findings effectively across teams.
Multitasking & Quality Assurance:
○ Manage multiple appeal cases concurrently while maintaining high standards for quality and turnaround time.
○ Contribute to internal quality assurance reviews and support process improvement initiatives.
Compliance & Industry Standards:
○ Stay current on CMS guidelines, UM criteria, and regulatory updates.
○ Ensure all appeals are resolved within required timelines and documented appropriately.
Recommended Minimum Skills Requirements (MSRs)
Technical Skills:
○ Strong understanding of Medicare UM and Appeals processes.
○ Familiarity with CMS guidelines, InterQual/MCG criteria, and clinical review standards.
○ Proficiency in using clinical platforms, documentation systems, and Microsoft Office Suite (Word, Excel, Outlook).
Soft Skills:
○ Strong case investigation, validation, and critical thinking abilities.
○ Excellent written and verbal communication skills in English.
○ High attention to detail, empathy, and sound clinical judgment.
Operational and Communication Skills:
○ Ability to manage multiple cases and meet CMS-mandated turnaround times.
○ Strong organizational, documentation, and time management skills.
○ Comfort working with cross-functional teams including payer nurses and IROs.
Location:
PHL Quezon City - Tera Tower 20th Floor
Language Requirements:
Time Type:
Full time
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At a glance
- Employment typeFull time
- Employer posted
- Added to ROLIVA
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Skills in this posting
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