Associate III, AG USRN – BPM

This is a fully remote position, open to applicants in Philippines.

📋 Description

• Efficiently and independently handle assigned transactions while adhering to required timelines and service level agreements (SLAs).

• Provide clarity on complex transactions to colleagues while ensuring quality and precision.

• Investigate and manage intricate grievances and appeals requests from both members and providers.

• Assess inpatient, outpatient, ambulatory, and ancillary services for medical necessity.

• Review, research, and compile documentation for appeals and grievances in alignment with regulatory and accreditation standards, including NCQA.

• Formulate recommendations to either uphold or deny appeals and collaborate with the Medical Director for further evaluation.

• Record and log appeal and grievance data in appropriate tracking systems.

• Compose written communications to providers, members, and regulatory bodies.

• Act as a subject matter expert on appeals, grievances, and quality-of-care matters.

• Employ leadership abilities.

• Assist with or carry out other essential functions as necessary.

⛳️ Requirements

• Valid unrestricted USRN mainland license.

• Minimum of 2 years of experience in utilization management or review.

• Proven clinical knowledge and experience relevant to patient care and healthcare delivery systems.

• Experience in Medicare Advantage is a plus.

• Strong written and verbal communication skills.

• Excellent customer service and interpersonal abilities.

• Proficient in using the current Microsoft Office Suite applications.

• Capability to apply clinical criteria and guidelines for medical necessity, level of care, and concurrent patient management.

• Familiarity with standard medical procedures and practices, along with current trends and developments in medicine and nursing, alternative care settings, and service levels.

• Understanding of relevant accreditation standards, and local, state, and federal regulations.

• Required experience in appeals and grievances.

• Strong problem-solving, facilitation, and analytical skills.

• Willingness to work in globally distributed teams and support weekend transactions based on business requirements.

🏝️ Benefits

• Comprehensive health benefits package.

• Opportunities for professional development and growth.

• Supportive work environment with a focus on teamwork.

• Flexible work arrangements.