Associate BPM Lead

Role Description
UST HealthProof is a trusted partner for health plans, offering an integrated ecosystem for health plan operations. Our BPaaS (Business Process as a Service) solutions manage complex administrative tasks, empowering our customers to focus on prioritizing the well-being of their members. Guided by our commitment to simplicity, honesty, and leadership, we collaborate closely with our customers to navigate challenges and work toward making affordable health care accessible to all.

We maintain a strong global presence, supported by a dedicated workforce of over 4,000 employees located around the world.

Our brand stands on the principles of simplicity, integrity, people-centricity, and leadership. We remain steadfast in our mission to unburden healthcare and ensure its equitable and effective reach to everyone.

UST HealthProof is seeking a highly motivated Utilization Review Registered Nurse (RN) to join our team. In this role, you will conduct prospective, concurrent, and retrospective reviews of inpatient, outpatient, ambulatory, and ancillary services, ensuring medical necessity, appropriate length of stay, intensity of service, and level of care. This includes reviewing and processing appeal requests initiated by providers, facilities, and members. You may also establish care plans and coordinate care across the health care continuum, which can include conducting member outreach assessments.

Key Responsibilities

• Review, research, and authorize requests for elective, direct, ancillary, urgent, emergency, and other services
• Contact relevant medical and support personnel to identify and recommend alternative treatments, service levels, and lengths of stay, utilizing approved clinical protocols
• Analyze, research, respond to, and prepare documentation for retrospective review requests and appeals, ensuring compliance with local, state, federal regulatory requirements, and designated accreditation standards such as NCQA
• Establish, coordinate, and communicate discharge planning needs with the appropriate internal and external parties
• Analyze patterns of care associated with disease progression, identify contractual services, and organize delivery through the appropriate channels
• Research and resolve issues related to benefits, member eligibility, non-elective and non-authorized services, coordination of benefits, care coordination, and similar matters
• Identify and document quality of care issues, resolving them directly or routing to the appropriate department for resolution
• Monitor out-of-area and out-of-network services, making recommendations for patient transfer to in-network services or alternative care plans as needed
• Develop and deliver targeted educational materials for the provider community regarding policies, procedures, benefits, and related topics
• When necessary and in collaboration with Provider Services, identify and negotiate reimbursement rates for non-contracted providers
• Perform other duties as assigned based on departmental needs

Qualifications

• Current, unrestricted Registered Nurse (RN) license is required
• Certification in Case Management is preferred depending on departmental assignment. Certification or progress toward certification is highly preferred and encouraged
• Minimum of two years of clinical experience, which may include acute patient care, discharge planning, case management, and utilization review
• Demonstrated clinical knowledge and experience relevant to patient care and healthcare delivery processes
• At least one year of experience in a health insurance plan or managed care environment is preferred

Skills And Competencies

• Excellent written and verbal communication skills, with a strong emphasis on customer service and interpersonal abilities.
• Proficiency in current Microsoft Office Suite applications
• Ability to apply clinical criteria and guidelines for determining medical necessity, setting and level of care, and concurrent patient management
• Knowledge of standard medical procedures and practices, current trends in medicine and nursing, and alternative care settings and service levels
• Familiarity with organizational policies and procedures, member benefits, and community resources
• Good understanding of applicable accreditation standards as well as local, state, and federal regulations
• Other relevant skills and abilities may be required based on departmental assignment

Skills
customer service,health insurance,managed care,utilization review,registered nurse,clinical knowledge,communication skills,customer service management,microsoft office