USRN - A&G

Responsibilities:

• Investigate and process complex grievances and appeals requests from members and providers.
• Perform medical necessity reviews for inpatient, outpatient, ambulatory, and ancillary services.
• Prepare recommendations and generate written correspondence to providers, members, and regulatory entities.

Qualifications:

• Unrestricted USRN mainland license with at least 2 years utilization management experience.
• Demonstrated clinical knowledge and experience relative to patient care and healthcare delivery processes.
• Strong problem-solving, facilitation, and analytical skills; appeals and grievance experience required.

Work Environment:

• Remote position based in the Philippines with globally distributed teams.
• Flexible to work on business need support weekend transactions.