Philippines- AG USRN- Associate III BPM

Wellframe; United States; Remote; USD 9,500 - 16,000; Full time

Job summary

Wellframe is seeking a USRN-licensed Associate III BPM in a remote role for the Philippines. The candidate will independently process transactions, review medical necessity, and handle grievances/appeals with accuracy and adherence to SLAs.

The role requires at least 2 years in utilization management, strong clinical knowledge, and excellent communication and customer service skills. Remote work with global teams may be required.

Qualifications

• Unrestricted USRN mainland license.
• Experience in utilization management / review.
• Strong written and verbal communication skills.
• Customer service and interpersonal skills.
• Knowledge of medical necessity criteria and regulations.

Responsibilities

• Investigate and process complex grievances and appeals from members and providers.
• Review medical records to determine medical necessity across services.
• Prepare documentation for appeals/grievances per regulatory standards.
• Make recommendations on upholding or denying appeals with Medical Director review.
• Document and log information in tracking systems.
• Generate correspondence to providers, members, and regulatory entities.
• Serve as SME for appeals, grievances, and quality of care issues.
• Collaborate with distributed teams and support weekend transactions.

Skills

USRN license

Utilization management

Clinical knowledge

Communication skills

Customer service

MS Office

Tools

Microsoft Office Suite

Job description

Philippines- AG USRN- Associate III BPM

Job Locations PH-Remote

ID 2026-8548

Position Type Full-Time

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