Associate III, BPM
Posted 1 month ago
You'll complete your application on HealthEdge's career site.
About the Role
This organization prioritizes innovation by utilizing modern technology and automation to reshape the healthcare industry. By offering a full range of digital tools—covering care management, payment integrity, and claims administration—the firm helps health plans optimize processes and elevate the member experience. The core mission involves breaking down information barriers and increasing payment precision to foster better collaboration between payers and providers for superior care delivery. Serving as an Associate III in the Business Process Management division, you will be instrumental in advancing these goals by applying your clinical background to improve healthcare efficiency and patient results. This position provides a fast-paced setting where you can combine your clinical insights with administrative rigor to support major healthcare projects.
Requirements
- You must maintain a valid, active Registered Nurse license within the U.S. and have a minimum of three years of hands-on clinical nursing practice.
- You need at least two years of work experience within the American healthcare sector, focusing specifically on case management or utilization management.
- Preference is given to applicants who hold an MCG certification or have previous experience using Guiding Care or HealthEdge HRCM software.
- You must show proficiency in handling intricate clinical records and display the analytical capabilities to assess medical services relative to defined accreditation and quality benchmarks.
Responsibilities
- You will conduct thorough evaluations of inpatient, ancillary, and outpatient services to confirm the medical necessity and correct level of care, as well as handle the appeals process.
- You will investigate and compile data for retrospective reviews in accordance with federal, state, and NCQA regulations.
- You will facilitate communication between support staff and medical professionals to determine suitable treatment options or care plans, while also organizing discharge logistics with internal and external partners.
- You will analyze matters concerning member eligibility, benefit coordination, and unauthorized procedures.
- You will engage in member outreach assessments and create specific educational resources for providers to promote a comprehensive grasp of procedures, policies, and benefits.
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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