Clinical Reviewer Specialty (CRS)

Target SD: No later than November 1, 2026

Work Setup/Location: ONSITE / BGC, Taguig within 6 months then transfer to Bridgetowne, QC

Work Schedule: Night Shift

The Clinical Reviewer Specialist plays a critical role in maximizing healthcare reimbursement by reviewing denied claims, identifying root causes of denials, and developing clinically and technically sound appeal strategies.

This position reviews medical records, coding and billing documentation, payer policies, and other relevant clinical information to determine the validity of denials and identify opportunities for reimbursement recovery. The Clinical Reviewer Specialist collaborates with healthcare providers and revenue cycle teams to obtain supporting documentation, develop persuasive appeals, and address recurring denial patterns.

The successful candidate will combine clinical expertise, coding and reimbursement knowledge, analytical ability, and strong written and verbal communication skills to support both revenue recovery and denial prevention initiatives.

This is a work-from-office opportunity for a clinically credentialed professional seeking to make a measurable impact on financial performance, claim quality, and revenue cycle outcomes.

Duties and Responsibilities:

Denial Review & Appeals

• Demonstrate and consistently apply the Client’s Core Values when interacting with team members, clients, providers, payers, and other stakeholders.
• Review denied claims to determine the specific denial reason, identify discrepancies, and assess opportunities for appeal.
• Analyze medical records, clinical documentation, billing records, coding information, and payer correspondence to determine the validity of denials.
• Research and interpret payer medical policies, reimbursement guidelines, contractual requirements, and applicable regulatory requirements.
• Apply knowledge of ICD-10-CM/PCS, CPT, HCPCS, modifiers, and other coding principles to identify coding-related denial issues and validate claim accuracy.
• Evaluate clinical documentation and supporting evidence to determine whether services were appropriately documented and supported.
• Develop clear, concise, and persuasive appeal arguments supported by clinical evidence, coding guidelines, payer policies, and applicable

Communication & Collaboration

• Communicates clearly and persuasively, both verbally and in writing, to collaborate with healthcare providers and present appeal arguments.
• Applies keen attention to detail to ensure accurate review and analysis of denied claims and medical records.
• Performs other duties as assigned.

Non-negotiable Requirements:

• Active certifications – Coding Certifications
• Must have active PHRN; USRN is a plus
• Minimum of 3 years of experience in healthcare revenue cycle management, medical billing, claims processing, or denial management.  
• With IP DRG Coding, Inpatient Surgery Coding, Inpatient E&M / Professional Coding, Inpatient HCC / Risk Adjustment Coding.

Preferred:

• Certified Denials and Appeals Specialist (CDAS) or equivalent denial management credential.
• Experience with EHR systems, such as Epic, and payer denial management portals.