Clinical Appeals Specialist

The Appeals Specialist is responsible for preparing, submitting, and following up on medical necessity and level-of-care appeals to payors. The role involves reviewing clinical documentation, summarizing key patient data, aligning with Care Guidelines (MCG/InterQual), and managing both written and verbal appeals, including real-time discussions with payor representatives. This position requires comfort with U.S. healthcare workflows, EMRs/EHRs, and frequent collaboration with U.S. counterparts.

Skills Required

• Identify and summarize abnormal vitals, labs, and imaging for payor-ready submissions.
• Assess day-to-day patient status and clinical trajectory from EMR documentation.
• Draft clear written appeals referencing MCG/InterQual; conduct verbal appeals with payors.
• Document call outcomes and maintain accurate case records.
• Basic-to-intermediate MS Word, Excel, Outlook 365; navigate EMRs/EHRs.
• Typing speed ≥ 30 WPM; strong computer literacy.
• Manage 8–10 cases/day; meet deadlines and quality standards.
• Strong medical writing, verbal communication, and teamwork.

Qualifications

• Clinical background preferred Doctors (MBBS, Ayush) and Physiotherapists; Utilization review/appeals experience is a plus.
• Familiarity with U.S. payors, denials, appeal timelines, and care guidelines (MCG/InterQual).
• Detail-oriented, organized, confident on calls, and comfortable working across multiple EMRs.

Shifts

• Day or Night shifts based on business need; mandatory availability for Indian night shifts for verbal appeals with U.S. payors.
• Willing to work U.S.-aligned schedules with potential weekend/holiday coverage.
• Attend weekly meetings with U.S. counterparts; maintain punctuality and attendance.

Job Types: Full-time, Permanent

Pay: ₹40,000.00 - ₹60,000.00 per month

Benefits:

• Health insurance
• Provident Fund

Work Location: In person