Philippines- AG USRN- Associate III BPM

Overview

USRN - A&G

Taguig, National Capital Region, Philippines

BE THE FIRST TO APPLY

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