Associate III, USRN – BPM

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

📋 Description

• Efficiently manage assigned transactions independently, ensuring they are processed within specified timeframes while upholding quality and accuracy in line with SLAs.

• Investigate and address complex grievances and appeals from both members and providers.

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

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

• Prepare recommendations regarding the approval or denial of appeals and collaborate with the Medical Director for additional review.

• Record and log appeal and grievance details in the appropriate tracking systems.

• Produce written communication for providers, members, and regulatory bodies.

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

• Employ leadership capabilities.

• Assist with or execute other pertinent essential functions as required.

⛳️ Requirements

• Unrestricted USRN mainland license.

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

• Proven clinical knowledge and experience related to patient care and healthcare delivery processes.

• Experience in Medicare Advantage is a plus.

• Exceptional written and verbal communication abilities.

• Outstanding customer service and interpersonal skills.

• Proficient in current industry Microsoft Office Suite applications on PC.

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

• Understanding of standard medical procedures/practices and their application, along with current trends and developments in medicine, nursing, alternative care settings, and service levels.

• Familiarity with applicable accreditation standards and local, state, and federal regulations.

• Experience in appeals and grievance processes is necessary.

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

• Flexibility to work within globally distributed teams and support weekend transactions as per business needs.

🏝️ Benefits

• Comprehensive health and wellness benefits.

• Opportunities for professional growth and development.

• Supportive team environment.

• Flexible work arrangements.