CLINICAL DENIALS & APPEALS Specialist_Onsite_Nightshift_BGC_Up to 75k

We are hiring for a CLINICAL DENIALS & APPEALS Specialist for a client based in BGC Taguig.

This is an Onsite work following a Nightshift schedule.

Salary is up to ₱75,000.00based on experience.

Non-Negotiable Requirements:

• Must have 1 yr of Appeals Writing and 3 yrs of Clinical experience and must either be a PHRN or USRN
• Clinical: 3–5 years acute care + 2–3 years ICU
• Education: BS Nursing
• Licensure: Active PHRN or USRN
• RCM: InterQual/MCG + US payer/regulations knowledge
• Systems: EMR (Epic, Cerner, Meditech)
• Communication: English proficiency (CEFR B2+)

Other Requirements:

• Experience supporting international BPO clients
• Familiarity with ATS tools and recruitment metrics

Key Responsibilities:

• Denials and Appeals Management
• Work denials and appeals timely, evaluating the denial reason including information from the payor and payor policies, reviewing the clinical documentation, assessing options and completing next steps
• Submit retro-authorizations in accordance with payor requirements in response to authorization denials
• Conducts medical necessity reviews, based on denial root cause, and prepares any required clinical documentation summaries to accompany appeals.
• Write and submit written appeals which include compelling arguments based on clinical documentation, third-party payer medical policies, and contract language. Appeals are submitted timely and tracked through final outcome.
• Document all actions taken and follow-up timely as needed related to resolving denials and appeals with third-party payers in a timely manner
• Tracks the status and progress of denials and appeals
• Completes relevant research to assist with completing the appeals process and to stay informed on best practices and policy reforms
• Executes internal and external correspondence accurately, clearly, concisely, and professionally while following organizational regulations
• Effectively handles all communications, including telephone, electronic, and paper correspondence from payers and departments within the business office
• Tracking, Reporting, and Trends
• Maintains data on the types of claims denied and root causes of denials
• Identify denial patterns and escalate to management as appropriate with sufficient information for additional follow-up, and/or root cause resolution
• Collaborate with management to recommend process changes to address root cause of denials and overall improvement to reduce A/R
• Prepares, maintains, assists with, and submits reports as required
• Compliance and Continuous Improvement
• Collaborate with team members to continually improve services, and engage in process and quality improvement activities
• Identify system improvement opportunities and contribute to the testing of system modifications
• Conducts relevant research to assist with completing the appeals process and to stay informed on best practices and policy reforms
• Complies with state and federal regulations, accreditation/compliance requirements, and Huron's policies, including those regarding fraud and abuse, confidentiality, and HIPAA
• Maintains a thorough understanding of federal and state regulations, as well as specific payer requirements and explanations of benefits, in order to identify and report billing compliances issues and payer discrepancies
• Participates in ongoing professional development to enhance job knowledge and performance
• Reports all identified compliance risks to appropriate leadership