Associate BPM Lead (Appeals & Grievances Analyst - Healthplans)

Taguig City, Metro Manila
Permanent
Full-time

2 months ago

Job Description:UST 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 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.As an Appeals & Grievances Analyst, you will manage and resolve appeals and grievances submitted by members, providers, and regulatory agencies. This role requires a deep understanding of Medicare Advantage regulations, client contracts, excellent analytical skills, and a commitment to ensuring compliance.

Review and analyze appeals and grievances to determine appropriate resolutions
Ensure compliance with CMS (Centers for Medicare & Medicaid Services) regulations and guidelines, and client specific rules
Conduct thorough investigations, including gathering and reviewing medical records, provider documentation, and member information
Prepare detailed case summaries and decision letters
Communicate effectively with members, providers, and regulatory agencies to resolve issues.
Maintain accurate and up-to-date records of all appeals and grievances
Identify trends and provide recommendations for process improvements
Collaborate with internal departments to ensure timely and accurate resolution of cases
Ability to work in a fast-paced production environment

Qualifications:

Bachelor's degree in healthcare administration, nursing, or a related field an advantage but not required
Minimum of 2 years of experience in Medicare Advantage or Medicare-related field such as Claims and/or UM.
In-depth knowledge of CMS regulations and guidelines
Strong analytical and problem-solving skills
Excellent written and verbal communication skills
Ability to work independently and as part of a team
Strong attention to detail and organizational skills
2 years of appeals and grievances experience preferred
Medical billing / coding knowledge an advantage
Amenable to working nightshift

Skills:Healthcare,Medical Management,Business ProcessAbout Company:UST is a global digital transformation solutions provider. For more than 20 years, UST has worked side by side with the world’s best companies to make a real impact through transformation. Powered by technology, inspired by people and led by purpose, UST partners with their clients from design to operation. With deep domain expertise and a future-proof philosophy, UST embeds innovation and agility into their clients’ organizations. With over 30,000 employees in 30 countries, UST builds for boundless impact—touching billions of lives in the process.

UST

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