Associate III, USRN – BPM
Posted 27 days ago
You'll complete your application on HealthEdge's career site.
About the Role
This organization focuses on evolving the medical sector through innovative digital tools for insurance providers, such as automated claims management, care coordination processes, and payment security software. By leveraging integrated tech and automation, these solutions help health insurance providers break down information barriers, increase billing precision, and elevate member satisfaction. As an Associate III, USRN – BPM, you will contribute to a group prioritized on clinical management and administrative precision. This remote position suits committed medical practitioners interested in helping health plans refine their functional productivity and care standards, while managing intricate clinical cases and ensuring the reliability of health insurance operations.
Requirements
- You must hold an active, unrestricted mainland USRN license and possess at least two years of professional experience in utilization review or management.
- You need proven clinical expertise in medical delivery and patient care, with required experience specifically in grievances and appeals.
- You must be skilled in utilizing clinical guidelines to assess level of care and medical necessity.
- You should demonstrate robust analytical, problem-solving, and facilitation capabilities, paired with superior verbal and written communication skills.
- Familiarity with accreditation requirements, Medicare Advantage, and applicable local, state, and federal laws is preferred.
- You must be proficient in Microsoft Office and be able to collaborate within global teams, including availability for weekend shifts if required.
Responsibilities
- You will manage assigned tasks autonomously while maintaining precision and meeting defined service level targets.
- You will primarily research and resolve intricate provider and member appeals and complaints.
- You will assess inpatient, ambulatory, outpatient, and ancillary care to confirm medical necessity and compose comprehensive documentation for appeals following regulatory and accreditation requirements like NCQA.
- You will develop suggestions to support or overturn appeals in collaboration with the Medical Director for final approval.
- You will record all data within tracking platforms, create official communications for relevant parties, and act as a clinical quality authority while exhibiting leadership in the medical review lifecycle.
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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