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Job Title: PHRN and Medical Allied 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 Mission: Hi, we're Concentrix. We’re a global technology and services leader that powers the brands of the future. We help well-known brands — the ones you use every day — improve their businesses with technology and integrated solutions, in over 70 countries. Company Overview: We power the brands of the future. Some call us a global technology and services leader. But we’re so much more. Human-centered, tech-powered, intelligence fuelled. Every day we’re busy helping over 2000 of the world's best brands solve their toughest business challenges. Whether it’s…… designing game-changing brand experiences, building and scaling secure AI technologies, or building loyalty to drive revenue. We’ve got them covered. But how? We design, build, and run fully integrated, end-to-end solutions across the entire enterprise, at speed and scale. We’re the strategic thinkers who designbrand-defining experiences. The technologists & engineers who buildsmarter solutions. And the operational experts who run it all and make it work seamlessly. By integrating strategy & design with data & analytics, enterprise technology, and digital operations. You could say, at the heart of everything we do lies a commitment to transform the way companies connect, interact, and grow across the world and into the future. Experience the power of Concentrix. Concentrix CVG Corporation is an EEO/AA/M/F/Vet/Disability Employer. Details Details Details
Cnx
PHL Quezon City - Tera Tower 20th Floor, Philippines
PHRN and Medical Allied.
more at Cnx.
26 Oct, 2026
Cnx
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