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Associate BPM Lead
3 weeks ago
Role Description
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
Skills
USRN,Healthcare,Appeals,Business Process
