PHIL- UM USRN- 专员 III BPM
PHIL- UM USRN- Associate III BPM
概述
USRN - 使用率管理
马尼拉大都会区，菲律宾塔吉格市
率先申请
职位描述
HealthEdge® 为健康保险公司提供人工智能驱动的运营基础设施，确保在日益竞争的市场中保持持久的财务优势。通过将索赔管理、支付完整性、护理管理等领域的集成技术平台与我们的 Enduring Edge BPaaS 交付模式相结合，我们利用人工智能推动可衡量的财务成果，这些成果随时间累积，使支付方能够降低费用，并在每个关键操作中表现更佳。HealthEdge 正在经历显著的增长，越来越多的健康计划客户选择我们的平台来现代化其运营并更有效地竞争。随着我们扩大市场影响力，我们正在投资于推动增长的人才。这是加入 HealthEdge 并建立直接塑造医疗技术未来的职业生涯的关键时刻。了解更多请访问 HealthEdge.com。
USRN 使用率管理将：
- 对住院、门诊、日间治疗和辅助服务进行前瞻性、同步性和回顾性审查，以确保医疗必要性、适当的住院时长、服务强度和护理级别，包括由供应商、设施和成员发起的申诉请求。
- 根据当地、州和联邦监管及指定认证（如 NCQA）标准，审查、研究并准备与回顾性审查请求和申诉相关的文件。
- 联系适当的医疗和支持人员，根据批准的临床协议，确定并推荐替代治疗方案、服务级别、住院时长等。
- 跟进院外/非网络服务，并就患者转至网络内服务和/或替代护理计划提出建议。
- 可能制定护理计划，并通过医疗保健连续体进行护理协调，包括对成员的接触评估。
- 与适当的内部和外部实体建立、协调并沟通出院计划需求。
- 审查与疾病进展相关的护理模式；识别合同服务并通过适当渠道组织交付。
- 研究并解决与福利、成员资格、非选择性和未授权服务、福利协调、护理协调等相关的问题。
- 开发并提供针对性的教育
查看英文原文
Overview
USRN - Utilization Management
Taguig, National Capital Region, Philippines
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JOB DESCRIPTION
HealthEdge® offers AI-powered operational infrastructure for health insurance companies, guaranteeing an enduring financial edge in an increasingly competitive market. By combining an integrated technology platform across claims administration, payment integrity, care management, and more with our Enduring Edge BPaaS delivery model, we harness AI to drive measurable financial outcomes that compound over time, enabling payers to reduce costs and execute better across every critical operation. HealthEdge is experiencing significant momentum, with a growing customer base of health plans choosing our platform to modernize their operations and compete more effectively. As we expand our market presence, we're investing in the people who power that growth. This is a pivotal moment to join HealthEdge and build a career where your work directly shapes the future of healthcare technology. Learn more at HealthEdge.com.
USRN Utilization Management will:
- 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.
Requirements:
- 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
Originally posted on Himalayas