USRN - A&G (Healthcare Appeals & Grievances)

Location: Remote in the Philippines; flexible to support weekend transactions based on business needs.

Company

hirify.global provides healthcare technology and services supporting health plan operations and clinical administration.

What you will do

• Investigate and process complex member and provider appeals and grievances.
• Review inpatient, outpatient, ambulatory, and ancillary services for medical necessity and appropriate level of care.
• Research cases and prepare documentation according to regulatory and accreditation standards, including NCQA requirements.
• Prepare recommendations to uphold or deny appeals and collaborate with the Medical Director on further review.
• Maintain appeal and grievance records in tracking systems and generate correspondence for members, providers, and regulatory entities.
• Serve as a subject matter expert on appeals, grievances, and quality-of-care issues.

Requirements

• Unrestricted USRN mainland license required.
• At least two years of experience in utilization management or clinical review.
• Required experience with appeals and grievances, plus clinical knowledge of patient care and healthcare delivery.
• Ability to apply clinical criteria for medical necessity, setting or level of care, and concurrent patient management.
• Knowledge of medical procedures, nursing practices, alternative care settings, accreditation standards, and applicable regulations.
• Strong written and verbal communication, customer service, interpersonal, problem-solving, facilitation, analytical, and Microsoft Office skills.

Nice to have

• Medicare Advantage experience.
• Leadership experience.

Culture & Benefits

• Remote work arrangement in the Philippines.
• Opportunity to work with globally distributed teams.
• Flexibility to support weekend transactions when required by business needs.