Senior USRN Appeals & Grievances Specialist

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

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.