Philippines- AG USRN- Associate III BPM

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

Job summary

The Blue Venture Fund is seeking an experienced USRN Associate III BPM for remote work in the Philippines. You will independently process transactions, clarify complex cases, and ensure output quality aligned with SLAs across appeals and grievances.

Responsibilities include investigating complex grievances, reviewing medical necessity across inpatient/outpatient services, documenting tracking systems, generating correspondence, and serving as a subject matter expert in appeals and quality of

Qualifications

• Unrestricted USRN mainland license.
• At least 2 years experience in utilization management / review.
• Medicare Advantage experience is an advantage.
• Excellent written and verbal communication skills.
• Healthcare documentation and regulatory knowledge.

Responsibilities

• 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 according to standards.
• Prepare recommendations to uphold or deny appeal and coordinate with Medical Director.
• Document and logs appeal/grievance information on 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 and support weekend transactions as needed.

Skills

USRN license

Utilization management

Communication skills

Customer service

Microsoft Office

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