UST is searching for an A&G USRN who will independently take customer support calls effectively and efficiently; follow the SOPs to complete the process and endeavour to resolve the issue, handle some escalated issues or escalate to a more knowledgeable person to resolve, in alignment with SLAs; and assists the Lead. In this role, you should independently be able to effectively and efficiently process the transactions assigned in a timely manner, clarify complex transactions to others and ensure that quality of output and accuracy of information is maintained, in alignment with SLAs.

 

Responsibilities:

Investigate and process complex grievances and appeals requests from members and providers Perform reviews of inpatient, outpatient, ambulatory and ancillary services for medical necessity Review, research, and prepare documentation related to appeals and grievances in accordance with local, state, and federal regulatory and designated accreditation (e.g., NCQA) standards Prepare recommendations to either uphold or deny appeal and work with the Medical Director for further review Document and logs appeal/grievance information on 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

 

Requirements:

Current, unrestricted, mainland USRN license 2-4 years of clinical experience which may include acute patient care, discharge planning, case management, utilization review, etc. Appeals and grievance experience required Demonstrated clinical knowledge and experience relative to patient care and healthcare delivery processes Medicare Advantage experience preferred Excellent written and verbal communication skills Excellent customer service and interpersonal skills 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 policies and procedures, member benefits, and community resources Knowledge of applicable accreditation standards, and local, state, and federal regulations Strong problem-solving skills, facilitation skills, and analytical skills Flexible to work in globally distributed teams as needed, and at times support weekend shifts