Associate III, AG USRN – BPM

🔥 0 minutes ago

🇵🇭 Philippines – Remote

⏰ Full Time

🟢 Junior

🟡 Mid-level

✨ Associate

👻 Ghost score 10%

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HealthEdge

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 2005

🏥 Healthcare

💼 Consulting

⚕️ Healthcare Insurance

Healthcare • Consulting • Healthcare Insurance

HealthEdge is a company that specializes in providing advanced solutions for healthcare payers through its HealthRules Solutions Suite. This suite includes a comprehensive digital claims administration processing system, care management workflow solutions, and payment integrity solutions, which aim to enhance operational efficiency and improve quality of care for health plans. By leveraging integrated technology and automation, HealthEdge helps health plans eliminate data silos, increase payment accuracy, and elevate member experience, thereby transforming the healthcare landscape for better collaboration and accessibility.

📋 Description

• Independently process assigned transactions efficiently and within required timelines and SLAs • Clarify complex transactions to others while maintaining quality and accuracy • Investigate and process complex grievances and appeals requests from members and providers • Review inpatient, outpatient, ambulatory, and ancillary services for medical necessity • Review, research, and prepare appeals and grievances documentation in accordance with regulatory and accreditation standards, including NCQA • Prepare recommendations to uphold or deny appeals and collaborate with the Medical Director for further review • Document and log appeal and grievance information in 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

🎯 Requirements

• 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, facilitation, and analytical skills • Flexibility to work in globally distributed teams and support weekend transactions based on business needs