Associate BPM Lead

6 days ago

Taguig, National Capital Region, Philippines UST USource Full time ₱1,200,000 - ₱2,400,000 per year

As an Appeals and Grievances USRN, one must be able to effectively and efficiently process the transactions assigned in a timely manner, clarify complex transactions as needed and ensure that quality of output and accuracy of information is maintained, in accordance to 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
  • Minimum of 2 years experience in utilization management / review
  • Demonstrated clinical knowledge and experience relative to patient care and healthcare delivery processes.
  • Medicare Advantage experience a plus but not required
  • Excellent written, verbal communication, customer service and interpersonal skills.
  • Working knowledge of current industry
  • Able to effectively use 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

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