Associate BPM Lead (USRN - Utilization Management)
UST
Date: 2 days ago
City: Taguig
Contract type: Full time
Role Description
Utilization Management,medical necessity,utilization review
- Perform prospective, concurrent, and retrospective reviews of inpatient, outpatient, ambulatory and ancillary services to ensure medical necessity, appropriate length of stay, the intensity of service, and level of care, including appeal requests initiated by providers, facilities, and members.
- Review, research, and prepare documentation related to retrospective review requests and appeals in accordance with local, state, and federal regulatory and designated accreditation (e.g., NCQA) standards.
- Contact appropriate medical and support personnel to identify and recommend an alternative treatment, service levels, length of stays, etc. using approved clinical protocols.
- Follow out-of-area/out-of-network services and make recommendations on patient transfer to in-network services and/or alternative plans of care.
- May establish care plans and coordinate care through the health care continuum including member outreach assessments.
- Establish, coordinate, and communicate discharge planning needs with appropriate internal and external entities.
- Review patterns of care associated with disease progression; identify contractual services and organize delivery through appropriate channels.
- Research and resolve issues related to benefits, member eligibility, non-elective and non-authorized services, coordination of benefits, care coordination as needed.
- Develop and deliver targeted education for the provider community related to policies, procedures, benefits when appropriate.
- This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required.
- Registered Nurse with current, unrestricted US Registered Nurse license
- 3+ years of direct, clinical nursing experience
- 2+ years’ experience in US Healthcare in utilization management or case management
- MCG Certification will be a plus
- Healthedge HRCM or Guiding Care experience is a plus
Utilization Management,medical necessity,utilization review
How to apply
To apply for this job you need to authorize on our website. If you don't have an account yet, please register.
Post a resumeSimilar jobs
L&D VTH Supervising Associate_Canada CBS and Markets Learning Specialist
EY,
Taguig
4 hours ago
At EY, you’ll have the chance to build a career as unique as you are, with the global scale, support, inclusive culture and technology to become the best version of you. And we’re counting on your unique voice and perspective to help EY become even better, too. Join us and build an exceptional experience for yourself, and a better working...
Data Engineer (Tableau)
TapTalent.ai,
Taguig
8 hours ago
An Alteryx and Tableau Architect designs and implements data analytics solutions, focusing on data preparation, automation, and visualization. They ensure seamless integration between data workflows and reporting tools to deliver actionable insights. This role involves collaborating with stakeholders to meet business needs and optimize processes.Required Skills Advanced proficiency in Alteryx Designer, including macros and in-database processing. Strong expertise in Tableau...
CRM Developer
CGI,
Taguig
2 days ago
Position DescriptionAct as a liaison between the IT Development group and business units for the development, implementation, and maintenance of new systems and/or enhancements of existing systems.Your future duties and responsibilities Evaluate new applications and identify systems requirements; Evaluate new IT developments and evolving business requirements, and recommend appropriate systems alternatives and/or enhancements to the current system; Create documentation and...
