PHIL- UM USRN- Associate III BPM

F-Prime Capital; United States; Remote; USD 75,000 - 105,000; Full time

Job summary

HealthEdge is seeking a USRN Utilization Management professional to join the USRN - Utilization Management team. This role involves reviewing medical necessity, length of stay, and level of care across inpatient and outpatient settings.

The ideal candidate is a registered nurse with current US license, with 3+ years of clinical nursing experience and 2+ years in utilization or case management, plus familiarity with NCQA standards and HealthEdge platform.

Qualifications

• Registered Nurse with current, unrestricted US RN license.
• 3+ years of direct, clinical nursing experience.
• 2+ years in US Healthcare in utilization management or case management.
• MCG Certification is a plus.
• HealthEdge HRCM or Guiding Care experience is a plus.

Responsibilities

• Perform prospective, concurrent, and retrospective reviews to ensure medical necessity, appropriate length of stay, the intensity of service, and level of care, including appeals.
• Review, research, and prepare documentation related to retrospective review requests and appeals per NCQA standards.
• Coordinate with appropriate medical and support personnel to identify and recommend alternative treatment plans.
• Follow out-of-area/out-of-network services and advise on patient transfer or alternative plans of care.
• Coordinate care through the health care continuum including member outreach assessments and discharge planning needs.

Skills

Clinical nursing experience

Care coordination

Medical necessity assessment

Patient education

Education

RN License

Job description

PHIL- UM USRN- Associate III BPM

PH-Remote

Full-Time

Overview

USRN - Utilization Management

Taguig, National Capital Region, Philippines

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JOB DESCRIPTION

HealthEdge® offers AI-powered operational infrastructure for health insurance companies, guaranteeing an enduring financial edge in an increasingly competitive market. By combining an integrated technology platform across claims administration, payment integrity, care management, and more with our Enduring Edge BPaaS delivery model, we harness AI to drive measurable financial outcomes that compound over time, enabling payers to reduce costs and execute better across every critical operation. HealthEdge is experiencing significant momentum, with a growing customer base of health plans choosing our platform to modernize their operations and compete more effectively. As we expand our market presence, we're investing in the people who power that growth. This is a pivotal moment to join HealthEdge and build a career where your work directly shapes the future of healthcare technology. Learn more at HealthEdge.com.

USRN Utilization Management will:

• Perform prospective, concurrent, and retrospective reviews of inpatient, outpatient, ambulatory and ancillary services to ensure medical necessity, appropriate length of stay, the intensity of service, and level of care, including appeal requests initiated by providers, facilities, and members.
• Review, research, and prepare documentation related to retrospective review requests and appeals in accordance with local, state, and federal regulatory and designated accreditation (e.g., NCQA) standards.
• Contact appropriate medical and support personnel to identify and recommend an alternative treatment, service levels, length of stays, etc. using approved clinical protocols.
• Follow out-of-area/out-of-network services and make recommendations on patient transfer to in-network services and/or alternative plans of care.
• May establish care plans and coordinate care through the health care continuum including member outreach assessments.
• Establish, coordinate, and communicate discharge planning needs with appropriate internal and external entities.
• Review patterns of care associated with disease progression; identify contractual services and organize delivery through appropriate channels.
• Research and resolve issues related to benefits, member eligibility, non-elective and non-authorized services, coordination of benefits, care coordination as needed.
• Develop and deliver targeted education for the provider community related to policies, procedures, benefits when appropriate.
• This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required.

Requirements:

• Registered Nurse with current, unrestricted US Registered Nurse license
• 3+ years of direct, clinical nursing experience
• 2+ years’ experience in US Healthcare in utilization management or case management
• MCG Certification will be a plus
• Healthedge HRCM or Guiding Care experience is a plus