Senior Appeals & Grievances Specialist (USRN Licensed)

HealthEdge; Philippines; À distance; PHP 450 000 - 750 000; Plein temps

Résumé du poste

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.

Responsabilités

• 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.

Connaissances

Clinical Knowledge

Medical Necessity

Documentation

Communication Skills

Customer Service

Analytical Skills

Team Collaboration

Regulatory Knowledge

Formation

Unrestricted USRN mainland license

Outils

Microsoft Office

Description du poste

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.