Clinical Bp_2026

Concentrix

Quezon City, Philippines
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Medicare um and appeals processes
Cms guidelines
Clinical review standards
** Concentrix is seeking an Appeals PHRN Specialist for its Medicare line of business in Quezon City, Philippines, focusing on Utilization Management and appeals processing. The ideal candidate should possess strong clinical review skills, familiarity with CMS guidelines, and the ability to manage multiple cases efficiently. **

Job Summary

  • 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.
  • Collaborate with onshore payer nurses and Independent Review Organizations (IROs) to collect and verify necessary documentation for appeal resolution.
  • Manage multiple appeal cases concurrently while maintaining high standards for quality and turnaround time.

Matching Summary

Match Score: 75

** Concentrix is seeking an Appeals PHRN Specialist for its Medicare line of business in Quezon City, Philippines, focusing on Utilization Management and appeals processing. The ideal candidate should possess strong clinical review skills, familiarity with CMS guidelines, and the ability to manage multiple cases efficiently. **

Skills & Requirements

Must-have

  • Medicare UM and Appeals processes
  • CMS guidelines
  • clinical review standards
  • case investigation and validation
  • English communication skills
  • high attention to detail

Nice-to-have

  • empathy and sound clinical judgment
  • cross-functional team collaboration

Key Requirements

  • Medicare UM or Appeals experience
  • Familiarity with InterQual/MCG criteria
  • Proficiency in clinical platforms
  • Proficiency in Microsoft Office Suite

Work Rights

Not specified

Tailored Resume

Cover Letter