Associate bpm lead (usrn - appeals & grievances)UST

Job 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 ProcessAbout Company: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.
UST

Taguig City, Metro Manila
Permanent
Full-time