Clinical BP_2026

Job description

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. 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