Remote Appeals & Grievances Nurse: BPM Associate III

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

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.