Associate III, USRN – BPM
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Job Description
USRN appeals specialist processing healthcare grievances and medical-necessity reviews for members and providers. Reviewing regulatory documentation and recommending appeal outcomes with Medical Director oversight.
Responsibilities:
- Independently process assigned transactions efficiently and within required timeframes, while maintaining quality and accuracy in alignment with SLAs
- Investigate and process complex grievances and appeals from members and providers
- Review inpatient, outpatient, ambulatory, and ancillary services for medical necessity
- Review, research, and prepare appeals and grievances documentation according to regulatory and accreditation standards, including NCQA
- Prepare recommendations to uphold or deny appeals and work with the Medical Director for further review
- Document and log appeal and grievance information in 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
Requirements:
- Unrestricted USRN mainland license
- At least 2 years experience in utilization management / review
- Demonstrated clinical knowledge and experience relative to patient care and healthcare delivery processes
- Medicare Advantage experience an advantage
- Excellent written and verbal communication skills
- Excellent customer service and interpersonal skills
- Working knowledge of current industry 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, facilitation, and analytical skills
- Flexibility to work in globally distributed teams and support weekend transactions based on business need
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