Medical Review and Appeals – RN

Job Description

Medical Review and Appeals — RNLead II – BPM

UST Health Proof is a trusted partner for health plans, offering an integrated ecosystem for health plan operations. Our BPaaS solutions manage complex admin tasks, allowing our customers to prioritize members’ well‑being. With our commitment to simplicity, honesty, and leadership, we navigate challenges with our customers to achieve affordable health care for all. We have a strong global presence and a dedicated workforce of over 4000 people spread across the world.

Our brand is built on the strong foundation of simplicity, integrity, people‑centricity, and leadership. We stay inspired in our goal to unburden healthcare and ensure it reaches all, equitably and effectively.

Perform prospective, concurrent and retrospective review of inpatient, outpatient, ambulatory and ancillary services to ensure medical necessity, appropriate length of stay, intensity of service and level of care, including appeal requests initiated by providers, facilities and members.

• Review, research and authorize requests for authorization of elective, direct, ancillary, urgent, emergency, etc. services.
• Contact appropriate medical and support personnel to identify and recommend alternative treatment, service levels, length of stays, etc. using approved clinical protocols.
• Analyze, research, respond to 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.
• Establish, coordinate and communicate discharge planning needs with appropriate internal and external entities.
• Analyze 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, Mental Health, Substance Abuse care coordination, etc.

This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required.

• Bachelor’s degree in nursing, allied health, business, or related field preferred.
• Registered Nurse with current unrestricted Registered Nurse license required.
• Certification in Case Management may be preferred based upon designated department assignment.
• Minimum two (2) years of clinical experience which may include acute patient care, discharge planning, case management, and utilization review, etc.
• Demonstrated clinical knowledge and experience relative to patient care and health care delivery processes. One (1) year health insurance plan experience or managed care environment preferred.
• 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 cost containment strategies, BCN/BCBSM policies and procedures, member benefits and community resources.
• Knowledge of applicable accreditation standards, local, state and federal regulations.

Full‑time, regular employees accrue up to 16 days of paid vacation per year, receive 6 days of paid sick leave each year (pro‑rated for new hires throughout the year), 10 paid holidays, and are eligible for paid bereavement leave. They are eligible to participate in the Company’s 401(k) Retirement Plan with employer matching. They and their dependents residing in the US are eligible for medical, dental, and vision insurance, as well as the following Company‑paid benefits: basic life insurance, accidental death and disability insurance, and short‑ and long‑term disability benefits.

Regular employees may purchase additional voluntary short‑term…