USRN - Appeals & Grievances Taguig, National Capital Region, Philippines

About the Role

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.

Responsibilities

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

Required Skills

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

USRN - Utilization Management Taguig, National Capital Region, Philippines

About the Role

USRN - Utilization Management JOB DESCRIPTION Perform prospective, concurrent, and retrospective reviews of inpatient, outpatient, ambulatory and ancillary services to ensure medical necessity, appropriate length of stay, the intensity of service, and level of care, including appeal requests initiated by providers, facilities, and members.

Responsibilities

Review, research, 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.
Contact appropriate medical and support personnel to identify and recommend an alternative treatment, service levels, length of stays, etc. using approved clinical protocols.
Follow out-of-area/out-of-network services and make recommendations on patient transfer to in-network services and/or alternative plans of care.
May establish care plans and coordinate care through the health care continuum including member outreach assessments.
Establish, coordinate, and communicate discharge planning needs with appropriate internal and external entities.
Review 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 as needed.
Develop and deliver targeted education for the provider community related to policies, procedures, benefits when appropriate.
This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required.

Qualifications

Registered Nurse with current, unrestricted US Registered Nurse license
3+ years of direct, clinical nursing experience
2+ years experience in US Healthcare in utilization management or case management

Required Skills

MCG Certification will be a plus
Healthedge HRCM or Guiding Care experience is a plus

Preferred Skills

MCG Certification will be a plus
Healthedge HRCM or Guiding Care experience is a plus

USRN Associate III