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Overview
USRN - A&G
Taguig, National Capital Region, Philippines
BE THE FIRST TO APPLY
JOB DESCRIPTION
In this role you should independently be able to effectively and efficiently process the transactions assigned in a timely manner, clarify complex transactions to others and ensure that quality of output and accuracy of information is maintained, in alignment with 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 At least 2 years experience in utilization management / review Demonstrated clinical knowledge and experience relative to patient care and healthcare delivery processes. Medicare Advantage experience an advantage 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 applicable accreditation standards, and local, state, and federal regulations
Appeals and grievance experience required.
Strong problem-solving skills, facilitation skills, and analytical skills.
Flexible to work in globally distributed teams and on business need support weekend transactions
