Philippines- AG USRN- Associate III BPM
Core
Independently process and investigate complex medical grievances and appeals, reviewing inpatient, outpatient, and ancillary services for medical necessity to ensure quality and accuracy in alignment with regulatory standards.
Role type
Senior Utilization Review Nurse (Appeals & Grievances)
Builds
Medical necessity determinations and appeal/grievance resolutions for members and providers
Domain
Healthcare / Utilization Management
Required skills
Utilization management, medical necessity review, appeals and grievances processing, regulatory compliance, clinical criteria application, documentation, written correspondence
Preferred skills
Medicare Advantage experience, leadership skills, problem-solving, facilitation, analytical skills
Technologies
Microsoft Office Suite
Responsibilities
Investigate and process complex grievances and appeals requests; 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 standards; Prepare recommendations to either uphold or deny appeal and work with the Medical Director for further review; Document and log 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
Seniority
Mid-level, hands-on IC