Associate III, BPM

Job not on LinkedIn

🔥 2 hours ago

🇵🇭 Philippines – Remote

⏰ Full Time

🟢 Junior

🟡 Mid-level

✨ Associate

👻 Ghost score 10%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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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

• Perform prospective, concurrent, and retrospective reviews of inpatient, outpatient, ambulatory and ancillary services to ensure medical necessity, appropriate length of stay, intensity of service, and level of care, including appeals. • Review, research, and prepare documentation for retrospective review requests and appeals according to local, state, federal, and accreditation standards such as NCQA. • Contact medical and support personnel to identify and recommend alternative treatments, service levels, lengths of stay, and plans of care using approved clinical protocols. • Follow out-of-area/out-of-network services and recommend patient transfers to in-network services or alternative plans of care. • Establish care plans and coordinate care through the healthcare continuum, including member outreach assessments. • Establish, coordinate, and communicate discharge planning needs with internal and external entities. • Review patterns of care associated with disease progression; identify contractual services and organize delivery through appropriate channels. • Research and resolve issues related to benefits, member eligibility, non-elective and non-authorized services, coordination of benefits, and care coordination. • Develop and deliver targeted education for providers concerning policies, procedures, and benefits when appropriate.

🎯 Requirements

• Registered Nurse with current, unrestricted US Registered Nurse license • 3+ years of direct, clinical nursing experience • 2+ years’ experience in US Healthcare in utilization management or case management • MCG Certification will be a plus • Healthedge HRCM or Guiding Care experience is a plus