Philippines- AG USRN- Associate III BPM

HealthEdge; Philippines; Remote; PHP 450,000 - 750,000; Full time

Job summary

HealthEdge in Taguig, Philippines, is seeking a qualified USRN-licensed professional to independently process complex grievances and appeals. The role requires clinical knowledge, regulatory familiarity, and strong communication to ensure quality output aligned with SLAs.

Responsibilities include reviews for medical necessity, documentation, and serving as a SME for appeals and quality of care issues. Weekend support may be required.

Qualifications

• Unrestricted USRN mainland license.
• At least 2 years of experience in utilization management / review.
• Demonstrated clinical knowledge related to patient care and healthcare delivery.
• Excellent written and verbal communication skills.
• Excellent customer service and interpersonal skills.
• Working knowledge of Microsoft Office Suite PC applications.
• Ability to apply clinical criteria for medical necessity, setting/level of care, and concurrent patient management.
• Knowledge of accreditation standards and local, state, and federal regulations.
• Appeals and grievance experience required.
• Willingness to work in globally distributed teams and weekend transactions.

Responsibilities

• Investigate and process complex grievances and appeals requests from members and providers.
• Review medical necessity for inpatient, outpatient, ambulatory and ancillary services.
• Prepare documentation related to appeals and grievances per regulatory and NCQA standards.
• Prepare recommendations to uphold or deny appeals and work with the Medical Director for review.
• Document and log appeal/grievance information on relevant tracking systems.
• Generate written correspondence to providers, members, and regulatory entities.
• Serve as a subject matter expert for appeals, grievances, and quality of care issues.
• Utilize leadership skills.
• Assist with or perform other relevant essential functions as required.

Skills

Clinical Knowledge

Medical Necessity

Documentation

Communication Skills

Customer Service

Analytical Skills

Team Collaboration

Regulatory Knowledge

Education

Unrestricted USRN mainland license

Tools

Microsoft Office

Job description

Overview

USRN - A&G

Taguig, National Capital Region, Philippines

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JOB DESCRIPTION

In this role you should independently be able to effectively and efficiently process the transactions assigned in a timely manner, clarify complex transactions to others and ensure that quality of output and accuracy of information is maintained, in alignment with SLAs.

• Investigate and process complex grievances and appeals requests from members and providers
• Perform reviews of inpatient, outpatient, ambulatory and ancillary services for medical necessity
• Review, research, and prepare documentation related to appeals and grievances in accordance with local, state, and federal regulatory and designated accreditation (e.g., NCQA) standards
• Prepare recommendations to either uphold or deny appeal and work with the Medical Director for further review
• Document and logs appeal/grievance information on relevant tracking systems
• Generate written correspondence to providers, members, and regulatory entities
• Serve as a subject matter expert for appeals, grievances, and quality of care issues
• Utilize leadership skills
• Assist with or perform other relevant essential functions as required

Qualifications:

• Unrestricted USRN mainland license
• At least 2 years experience in utilization management / review
• Demonstrated clinical knowledge and experience relative to patient care and healthcare delivery processes. Medicare Advantage experience an advantage
• Excellent written and verbal communication skills.
• Excellent customer service and interpersonal skills.
• Working knowledge of current industry Microsoft Office Suite PC applications.
• Ability to apply clinical criteria/guidelines for medical necessity, setting/level of care, and concurrent patient management
• Knowledge of current standard medical procedures/practices and their application as well as current trends and developments in medicine and nursing, alternative care settings, and levels of service
• Knowledge of applicable accreditation standards, and local, state, and federal regulations
• Appeals and grievance experience required.
• Strong problem-solving skills, facilitation skills, and analytical skills.
• Flexible to work in globally distributed teams and on business need support weekend transactions