PHRN – Grievance & Case Appeals

About the Role

We are looking for a Philippine Registered Nurse (PHRN) to support grievance and case appeals activities within a healthcare operations environment.

The role involves reviewing healthcare-related cases, analyzing clinical information and documentation, and supporting grievance and appeal processes in accordance with established guidelines, policies, and procedures.

The successful candidate should have strong clinical knowledge, analytical skills, attention to detail, and the ability to review healthcare information accurately and professionally.

Key Responsibilities

• Review and assess healthcare-related grievances and case appeals.

• Analyze clinical documentation, medical records, and case information as required.

• Apply clinical knowledge when reviewing cases and supporting appeal-related decisions.

• Ensure case reviews are completed accurately and within defined timelines.

• Identify relevant clinical information, discrepancies, and missing documentation.

• Follow established healthcare policies, procedures, quality standards, and regulatory requirements.

• Maintain accurate and complete documentation for reviewed cases.

• Coordinate with relevant healthcare and operations teams regarding case-related concerns.

• Escalate complex cases or issues according to established procedures.

• Maintain confidentiality of patient and healthcare information.

• Meet productivity, quality, and turnaround-time requirements.

• Participate in training, coaching, quality reviews, and process updates.

• Adapt to process changes and continuously improve knowledge of grievance and appeals procedures.

Required Skills & Qualifications

• Philippine Registered Nurse (PHRN) qualification.

• Strong clinical knowledge and understanding of healthcare processes.

• Strong analytical and case-review skills.

• Excellent attention to detail.

• Ability to interpret and assess clinical documentation.

• Strong written and verbal communication skills.

• Ability to work with confidential and sensitive healthcare information.

• Good decision-making and problem-solving abilities.

• Ability to work independently while collaborating effectively with teams.

• Willingness to work onsite during training and transition to a hybrid setup after training.

Work Setup

• Position: PHRN – Grievance & Case Appeals

• Location: Taguig

• Work Setup: Hybrid after Training

• Training: Onsite

• Employment Type: Full Time

• Experience: To Confirm