About this role
Overview
USRN - A&G
Taguig, National Capital Region, Philippines
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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.
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Investigate and process complex grievances and appeals requests from members and providers
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Perform reviews of inpatient, outpatient, ambulatory and ancillary services for medical necessity
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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
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Prepare recommendations to either uphold or deny appeal and work with the Medical Director for further review
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Document and logs appeal/grievance information on relevant tracking systems
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Generate written correspondence to providers, members, and regulatory entities
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Serve as a subject matter expert for appeals, grievances, and quality of care issues
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Utilize leadership skills
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Assist with or perform other relevant essential functions as required
Qualifications
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Unrestricted USRN mainland license
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At least 2 years experience in utilization management / review
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Demonstrated clinical knowledge and experience relative to patient care and healthcare delivery processes. Medicare Advantage experience an advantage
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Excellent written and verbal communication skills.
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Excellent customer service and interpersonal skills.
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Working knowledge of current industry Microsoft Office Suite PC applications.
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Ability to apply clinical criteria/guidelines for medical necessity, setting/level of care, and concurrent patient management
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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
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Knowledge of applicable accreditation standards, and local, state, and federal regulations
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Appeals and grievance experience required.
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Strong problem-solving skills, facilitation skills, and analytical skills.
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Flexible to work in globally distributed teams and on business need support weekend transactions