RN/USRN - Clinical Denials and Appeals

Job Description

Schedule: Full Onsite | Night Shift

Job Overview

We are urgently looking for experienced RN/USRN professionals to join our Clinical Denials & Appeals team. This role plays a critical part in reviewing denied claims, conducting medical necessity reviews, and preparing strong, evidence‑based clinical appeals in compliance with U.S. healthcare regulations and payer guidelines.

• Review denial cases for medical necessity and level of care
• Analyze denial reasons using InterQual or MCG guidelines
• Write clear, accurate, and persuasive clinical appeal letters
• Utilize hospital EMRs such as Epic, Cerner, or Meditech
• Track appeals through denial and appeal management systems
• Ensure timely submission and follow‑up of appeals in accordance with payer timelines
• Collaborate with internal teams to resolve complex denial issues
• Maintain complete and accurate documentation for tracking and reporting

Qualifications:

• Bachelor of Science in Nursing (BSN) graduate
• Active RN or USRN license
• At least 1 year experience in writing clinical appeals
• Minimum 3 years hospital acute care experience (Med‑Surg or similar)
• At least 2 years ICU experience
• Hands‑on experience with InterQual or MCG
• Strong knowledge of U.S. insurance and government healthcare programs
• Experience using hospital EMRs (Epic, Cerner, Meditech)
• Exposure to denial and appeal tracking systems
• Excellent English communication skills (written & verbal)

• Background in case management, utilization review, or clinical appeals
• ACMA or related certification
• Experience handling high‑volume denial and appeal cases

• Competitive salary up to PHP 75,000
• Stable full onsite role in BGC, Taguig
• Opportunity to work on U.S. healthcare accounts
• Career growth within clinical and revenue cycle management