Associate III, AG USRN – BPM
Posted 27 days ago
You'll complete your application on HealthEdge's career site.
About the Role
This organization strives to modernize the healthcare industry by offering sophisticated software solutions for payers, such as end-to-end claims administration systems, care management processes, and payment verification tools. By utilizing automated and unified technology, the firm assists health plans in removing functional barriers, improving payment precision, and boosting the standard of member care. The Associate III, AG USRN position is a central function dedicated to overseeing intricate grievance and appeals workflows. You will join an agile, international team that prioritizes both clinical skill and streamlined operations. This position is intended for experts dedicated to optimizing patient results and ensuring that medical services meet rigorous accreditation and regulatory requirements.
Requirements
- You must maintain an active, unrestricted USRN license in the US mainland.
- You are required to have a minimum of two years of work experience in clinical review or utilization management.
- You must exhibit advanced clinical proficiency in patient care, healthcare service delivery, current nursing and medical trends, and standard medical practices.
- Direct experience with grievances and appeals is mandatory, while familiarity with Medicare Advantage is preferred.
- You should demonstrate exceptional verbal and written communication skills, interpersonal talent for customer service, and competence in Microsoft Office Suite.
- You need to be capable of applying medical necessity criteria and possess comprehensive knowledge of accreditation standards along with federal, state, and local healthcare laws.
- You must possess analytical problem-solving skills and the adaptability to work effectively within an international, distributed team.
Responsibilities
- You will manage your assigned tasks autonomously while strictly meeting quality benchmarks and operational deadlines.
- Your primary duties include researching and handling sophisticated appeals and grievances submitted by providers and members.
- You will evaluate services spanning inpatient, outpatient, ambulatory, and ancillary care to confirm medical necessity.
- It is your responsibility to draft thorough documentation for appeals that aligns with regulatory and NCQA standards.
- You will develop recommendations for upholding or rejecting appeals, frequently coordinating with the Medical Director for final approval.
- You will maintain precise records within tracking systems and produce official communications for regulatory bodies and providers.
- As a subject matter expert, you will provide guidance on quality-of-care matters and assist with leadership responsibilities to help the team meet its goals.
Note: This listing is summarized and paraphrased by WorkNow from a publicly posted role. For the original wording and full details, please refer to the employer's official posting.
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