Associate BPM Lead

4 days ago


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

2 Openings

Taguig

Role description

UST HealthProof is a trusted partner for health plans, offering an integrated ecosystem for health plan operations. Our BPaaS solutions manage complex admin tasks, allowing our customers to prioritize members' well-being. With our commitment to simplicity, honesty, and leadership, we navigate challenges with our customers to achieve affordable health care for all. We have a strong global presence and a dedicated workforce of over 4000 people spread across the world. Our brand is built on the strong foundation of simplicity, integrity, people-centricity, and leadership. We stay inspired in our goal to unburden healthcare and ensure it reaches all, equitably and effectively.

UST HealthProof is searching for a highly motivated Utilization Review RN to join our team. As a Utilization Review US Registered Nurse, you will perform prospective, concurrent and retrospective review of inpatient, outpatient, ambulatory and ancillary services to ensure medical necessity, appropriate length of stay, intensity of service and level of care, including appeal requests initiated by providers, facilities and members. May establish care plans and coordinate care through the health care continuum including member outreach assessments.

  • Review, research and authorize requests for authorization of elective, direct, ancillary, urgent, emergency, etc. services. Contact appropriate medical and support personnel to identify and recommend alternative treatment, service levels, length of stays, etc. using approved clinical protocols
  • Analyze, research, respond to and prepare documentation related to retrospective review requests and appeals in accordance with local, state and federal regulatory and designated accreditation (e.g. NCQA) standards
  • Establish, coordinate, and communicate discharge planning needs with appropriate internal and external entities
  • Analyze 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, care coordination, etc
  • Identify and document quality of care issues; resolve or route to appropriate area for resolution
  • Follow out-of-area/out-of-network services and make recommendations on patient transfer to in-network services and/or alternative plans of care
  • Develop and deliver targeted education for provider community related to policies, procedures, benefits, etc
  • As needed and in conjunction with Provider Services, may identify and negotiate reimbursement rates for non-contracted providers for services
  • Other duties may be assigned based on designated department assignment

Qualifications:

  • Mainland and current unrestricted US Registered Nurse license required
  • Certification in Case Management may be preferred based upon designated department assignment. Certification or progress toward certification is highly preferred and encouraged
  • Minimum of 2 years' clinical experience which may include acute patient care, discharge planning, case management, and utilization review, etc
  • Demonstrated clinical knowledge and experience relative to patient care and health care delivery processes
  • Minimum 1 year health insurance plan experience or managed care environment preferred

Skills & Competencies:

  • 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 policies and procedures, member benefits and community resources
  • Knowledge of applicable accreditation standards, local, state and federal regulations
  • Other related skills and/or abilities may be required to perform this job based upon designated department assignment
Skills

USRN,Healthcare,Medical Management

About UST

UST is a global digital transformation solutions provider. For more than 20 years, UST has worked side by side with the world's best companies to make a real impact through transformation. Powered by technology, inspired by people and led by purpose, UST partners with their clients from design to operation. With deep domain expertise and a future-proof philosophy, UST embeds innovation and agility into their clients' organizations. With over 30,000 employees in 30 countries, UST builds for boundless impact—touching billions of lives in the process.


  • BPM Lead

    4 days ago


    Taguig, National Capital Region, Philippines UST Full time $80,000 - $120,000 per year

    Role DescriptionThe primary objective of The Call Center Team Leader/Supervisor is to implement policies and procedures to foster an environment of excellence in servicing healthcare customers. This includes leading and managing a team of 12-15 Call Center agents, examiners, adjusters, extensive interaction with client organization and multiple stakeholders,...

  • Associate BPM Lead

    2 days ago


    Taguig, National Capital Region, Philippines UST Full time $70,000 - $120,000 per year

    Role DescriptionWe are seeking an experienced and analytical Quality Assurance Lead to oversee and elevate the quality of service in our healthcare call center operations. This role involves supervising QA Analysts, evaluating agent performance, and collaborating with training and operations teams to ensure compliance with healthcare regulations and service...

  • BPM Associate

    4 days ago


    Taguig, National Capital Region, Philippines UST Full time ₱150,000 - ₱250,000 per year

    4 OpeningsTaguigRole descriptionThe Customer Service Associate will provide exceptional customer service to customers via inbound Call Center Operations.Duties/Responsibilities:Receive and respond to inbound phone calls for customer assistanceRespond to outbound phone call requestsDocument all calls in ticketing and tracking systemsRespond to customer...


  • Taguig, National Capital Region, Philippines UST Full time ₱600,000 - ₱1,200,000 per year

    Role DescriptionWe are seeking a highly motivated and customer-focused Healthcare Helpdesk Associate to provide frontline support to patients, healthcare professionals, and internal teams. The role involves handling inquiries, troubleshooting issues, and ensuring seamless communication between various stakeholders in a healthcare setting. The associate will...

  • BPM Lead

    4 days ago


    Taguig, National Capital Region, Philippines UST Full time ₱900,000 - ₱1,200,000 per year

    Role DescriptionUnder general supervision, the Lead is responsible for supervising the assigned team and ensure that the team adheres to SLAs specified by the client or process for productivity, achieving expected quality and revenue goals and schedule adherence. The Lead is considered a mentor, trainer, developer of less tenured team members. Responsible...

  • Associate BPM Lead

    2 days ago


    Taguig, National Capital Region, Philippines UST Full time ₱900,000 - ₱1,200,000 per year

    1 OpeningTaguigRole descriptionAs 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...

  • Associate BPM Lead

    2 days ago


    Taguig, National Capital Region, Philippines UST USource Full time ₱900,000 - ₱1,200,000 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...


  • Taguig, National Capital Region, Philippines UST Full time ₱250,000 - ₱500,000 per year

    25 OpeningsTaguigRole descriptionReporting to the Customer Service Manager, the Customer Service Associate will provide exceptional customer service to the UST customers via inbound Call Center Operations.Duties/Responsibilities:Receive and respond to inbound phone calls for customer assistanceRespond to outbound phone call requestsDocument all calls in...


  • Taguig, National Capital Region, Philippines UST Full time $40,000 - $80,000 per year

    8 OpeningsTaguigRole descriptionAssign appropriate ICD-10-CM codes, mapping to risk adjustment models for Medicare Advantage and ACA Commercial ProjectsAssign Flag events and CDI for documentation discrepanciesComply with the Standards of Ethical Coding as set forth by the American Health Information Management Association and adhere to official coding...


  • Taguig, National Capital Region, Philippines UST Full time ₱900,000 - ₱1,200,000 per year

    1 OpeningTaguigRole descriptionWe are searching for an Appeals and Grievances Intake Analyst who will support coordination of appeals and grievances intake, request medical records, and process member/provider requests as well as promote and support Appeals and Grievances team as required.Provide support services to team members triaging and completing...