Philippines- AG USRN- Associate III BPM

HealthEdge is hiring a USRN to process and review complex member and provider appeals and grievances. The role evaluates medical necessity, prepares recommendations and correspondence, and maintains accurate documentation in line with service-level agreements and regulatory standards.

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

Utilize leadership skills

Assist with or perform other relevant essential functions as required

Preferred

Medicare Advantage experience an advantage

Medicare Advantage Experience

Company

Healthcare technology solutions connecting health plans, providers, and patients

Boston, Massachusetts, USA

http://www.healthedge.com/

Founded in 2004

5001-10000 employees

Qualifications

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

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 skills, facilitation skills, and analytical skills

Flexible to work in globally distributed teams

Medicare Advantage experience an advantage

Required skills

Unrestricted USRN License, Utilization Management, Clinical Knowledge, Medicare Advantage, Microsoft Office Suite, Medical Necessity Review, Appeals and Grievances, Accreditation Standards, Healthcare Regulations, Medical Procedures and Practices

Preferred skills

Medicare Advantage experience an advantage, Glassdoor, 3.4, Boston, Massachusetts, USA, http://www.healthedge.com, Late Stage, Total Funding, $97.78M, Key Investors, Medica, Oaktree Specialty Lending, Psilos Group, 2025-04-08, Acquired, 2020-03-09, Private Equity, 2017-07-14, Series Unknown· $34M, Leadership Team, Alex Saltzman, Kevin Adams, Chief Executive Officer, Recent News, Washington Technology, 2026-06-03, Newswire, 2026-04-08, EIN Presswire, 2026-02-27, Company data provided by

Experience

2+ years