Remote BPM Appeals Specialist III

Wellframe; United States; Remote; 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

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