Clinical Denials and UMR | Non Voice (PHRN - Pasay City)

This role involves reviewing medical cases, ensuring compliance with payer requirements, and assisting in the appeals process for denied claims.

Key Responsibilities:

• Conduct utilization reviews to assess medical necessity, appropriateness, and efficiency of healthcare services.
• Analyze clinical denials and collaborate with internal teams to determine appeal strategies.
• Review medical records and ensure compliance with insurance policies and industry guidelines.
• Assist in preparing clinical appeals and reconsideration letters for denied claims.
• Provide medical rationale and justifications based on clinical evidence and payer guidelines.
• Communicate with insurance providers, physicians, and other healthcare professionals regarding authorization approvals or denials.
• Stay updated on healthcare policies, medical guidelines, and payer requirements to optimize claims processing.
• Ensure compliance with HIPAA regulations, data privacy laws, and company protocols.

Qualifications:

• Must be a Licensed Philippines Nurse (PH RN).
• At least one (1) year of hospital bedside experience (ICU, ER, Med-Surgery, or similar preferred).
• Experience in utilization review, clinical denials management, or medical claims processing is a must.
• Strong understanding of insurance policies, medical necessity criteria, and appeal processes.
• Excellent critical thinking, analytical, and problem-solving skills.
• Effective written and verbal communication skills.
• Proficiency in medical terminology, coding (ICD-10, CPT), and healthcare documentation is a plus.
• Ability to work in a fast-paced BPO environment with shifting schedules.