Philippines- AG USRN- Associate III BPM

HealthEdge Software, Inc.; Taguig; On-site; PHP 420,000 - 660,000; Full time

Job summary

HealthEdge Software, Inc. in Taguig, National Capital Region, Philippines, seeks an experienced USRN to independently process transactions, review medical necessity, and handle appeals with accuracy and timely SLAs.

You will investigate complex grievances, prepare documentation for regulatory standards, and act as a subject matter expert on appeals, grievances, and quality of care issues, collaborating with the Medical Director as needed.

Qualifications

• Valid USRN license required.
• Minimum 2 years in utilization management or review.
• Strong written and verbal communication.
• Excellent customer service and interpersonal abilities.
• Proficient with Microsoft Office applications.
• Knowledge of clinical criteria and medical necessity.
• Familiar with accreditation standards and regulations.
• Experience with appeals and grievances preferred.

Responsibilities

• Investigate and process complex grievances and appeals for members and providers.
• Review inpatient, outpatient, ambulatory and ancillary services for medical necessity.
• Prepare documentation related to appeals in line with standards.
• Provide recommendations with Medical Director review.
• Document logs of appeal/grievance information.
• Generate correspondence to providers, members, and regulators.
• Serve as SME for appeals, grievances, and quality of care issues.
• Utilize leadership skills.
• Assist with other essential functions as required.

Skills

Communication skills

Customer service

Interpersonal skills

Problem-solving

Analytical skills

Team collaboration

Microsoft Office

Education

Unrestricted USRN mainland license

Tools

Microsoft Office Suite

Job description

Overview

USRN - A&G

Taguig, National Capital Region, Philippines

BE THE FIRST TO APPLY

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