Philippines- AG USRN- Associate III BPM

HealthEdge; Taguig; Remote; PHP 600,000 - 900,000; Full time

Job summary

USRN - A&G in Taguig invites a dedicated nursing professional to independently process complex grievances and appeals, ensuring accuracy and SLA adherence. You will review medical necessity across inpatient, outpatient, and ancillary services, and prepare documentation for regulatory standards, collaborating with the Medical Director as needed.

The role requires an unrestricted USRN license, at least 2 years in utilization management, strong communication, and the ability to work with globally

Qualifications

• Unrestricted USRN mainland license is required.
• Minimum 2 years in utilization management or review.
• Clinical knowledge relevant to patient care and care delivery processes.
• Experience with Medicare Advantage is a plus.

Responsibilities

• Investigate and process complex grievances and appeals from members and providers.
• Review services for medical necessity across inpatient, outpatient, and ancillary settings.
• Prepare documentation for appeals/Grievances in line with regulatory standards.
• Collaborate with Medical Director for further review as needed.
• Document and log appeal/grievance data in tracking systems.
• Generate written communications to providers, members, and regulators.
• Serve as SME for appeals and quality of care issues.
• Utilize leadership and assist with essential tasks as required.

Skills

Utilization mgmt

Medical knowledge

Communication

MS Office

Problem solving

Teamwork

Weekend support

Education

USRN license

Tools

Office Suite

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