Qualifications

Responsibilities include reviewing denial letters, determination and data entry of audit recommendations, and responsibility for professional and effective appeal responses that are submitted timely under payer timeframes.

Correspondence with insurance providers—to appeal insurance decisions contrary to the best interests of the patient.
Correspondence with patients—to identify whether their current symptoms warrant further care.
Correspondence with patients’ families—to keep all loved ones informed on a patient’s health and on the status of the appeals process.
Report creation and submission of an appeal—complete with all necessary details to inform insurance carriers of a patient’s continued needs.
Research into current healthcare regulations and stipulations—to form the basis for any necessary appeal.
Investigation into a patient’s history treatment—to better warrant their need for continual care.
Reviewing response letters from insurance carriers—and following up whenever necessary.

Competencies
Knowledge, Skills and Attributes

In order to become a clinical appeals specialist, one should have the following competencies:

Interpersonal communication – the ability to expertly communicate with insurance providers, patients, and patient families regarding continued care and the status of any appeals process.

Research – the ability to quickly comb through healthcare regulations to find litigation that will strengthen an appeals claim.
Reporting – the ability to draft reports documenting the progress of any appeals process through the completion of the appeal.
Problem solving – the ability to understand a patient’s issues and take steps to remedy them.
Teamwork – the ability to work in tandem with healthcare staffing, nurses, doctors, and insurance personnel to ensure that patients receive appropriate levels of care.

Cost of Education and Training

Public/State University and College average per semester

By virtue of Republic Act 10931, undergraduate students accepted to SUCs are covered for free tuition and other school fees.

Private University/College average per semester:
Php 26,000.00 – 56,000
per semester

Licensure Examination for Nurses, Medical Technology, NDT (medical allied courses)

Employment Prospects
Monthly Salary Range
Php 30,000 - Php 52,000

Industries

IT-BPM
Manufacturing
PublicAdministration
Compulsory Social Security
Ownership,Dwellingsand
WholesaleandRetail Trade
andDefense
Real Estate

Propects for Career Advancement

Clinical Appeals Specialist is an occupation evident in the IT BPM industry. The employment prospect for this occupation highlights the global in-house subsector particularly on the industry-specific services for Telecom, Healthcare, Insurance and Pharmaceutical. In addition, the IT-BPM industry ended 2020 with 1.32 million direct employees, 1.8 percent higher compared to 2019.

While the projected revenue growth rate for this roadmap period is considerably lower than past CAGR of 17% between 2010 and 2016, the Philippines is still projected to outperform the global IT-BPM sector with revenue growth at 5.6% (from 2016 to 2022) and as a result, will increase its share of the global IT-BPM outsourcing sector from 12.7% in 2016 to 15.5% by 2022. The relatively slower growth is also seen as
a sign of a maturing sector and the anticipated impact of technology.

The Clinical Appeals Specialist is a mid-level position preceding the Clinical Appeals Associate. The next prospect for this position is becoming a Clinical Appeals Manager.