Associate III, USRN – BPM

• 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

• 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