UM Appeals Nurse
Makati, NCR, Philippines
5d ago

It’s Time For A Change

Your Future Evolves Here

Evolent Health has a bold mission to change the health of the U.S. by changing the way health care is delivered. Our pursuit of this mission is the driving force that brings us to work each day.

We believe in embracing new ideas, challenging ourselves and failing forward. We respect and celebrate individual talents and team wins.

We have fun while working hard and Evolenteers often make a difference working in everything from scrubs to jeans.

Are we growing? Absolutely and Globally. In 2021 we grew our teams by almost 50% and continue to grow even more in 2022. Are we recognized as a company you are supported by for your career and growth, and a great place to work?

Definitely. Evolent Health International (Pune, India) has been certified as Great Places to Work in 2021. In 2020 and 2021 Evolent in the U.

S. was both named Best Company for Women to Advance list by and earned a perfect score on the Human Rights Campaign (HRC) Foundation’s Corporate Equality Index (CEI).

This index is the nation's foremost benchmarking survey and report measuring corporate policies and practices related to LGBTQ+ workplace equality.

We recognize employees that live our values, give back to our communities each year, and are champions for bringing our whole selves to work each day.

If you’re looking for a place where your work can be personally and professionally rewarding, don’t just join a company with a mission.

Join a mission with a company behind it.

Utilization Management Appeals Nurse

Roles & Responsibilities

  • Act as a member advocate addressing member or provider concerns
  • Analyze, review and evaluate appeals and grievances in compliance with state, federal and other regulatory requirements
  • Process appeals and grievances in compliance with client, state, and regulatory required timeframes
  • Review appeals for any denied patient services
  • Research, investigate and summarize complex issues using state and federally mandated benefits, EOC / COC / SPD benefit language, CMS guidelines, Medical Policies and InterQual criteria
  • Prepare cases for Medical Director and / or External Review
  • Develop timely and professional documentation and correspondence that ensures accuracy, completeness and conformance to quality and regulatory standards
  • Formulate determination language that resolves member or provider issues in a manner consistent with regulatory and accrediting agency requirements
  • Recognize and report potential quality of care concerns
  • Utilize multiple internal and external computer applications and programs
  • Meet established productivity and quality standards
  • Perform other duties as assigned
  • Qualifications

  • An active and unrestricted Nursing License in the Philippines and in the mainland US
  • Minimum one (1) year experience in Utilization Management, exposure to appeals and grievances is an advantage
  • Strong clinical knowledge, direct clinical patient care experience for at least a year is preferred
  • Experience with clinical decision-making criteria sets (i.e. MCG, InterQual)
  • Experience in managed care and health insurance preferred
  • Excellent written and oral communication skills
  • Proficiency with PC-based software programs including Word, Excel and Outlook
  • Strong critical thinking, analytical, research and organizational skills
  • Ability to work remotely and independently
  • Basic knowledge and understanding of medical coding and claims processing
  • Hours of Training and Operations : US Business Hours
  • Trainees will be required to maintain regular attendance and successfully complete the required training and demonstrate proficiency of the material at the end of training.
  • Compensation & Benefits

  • Earn as much as ₱85,000 up to ₱95,000 per month;
  • HMO coverage includes you and a dependent.
  • Evolent Health is an equal opportunity employer and considers all qualified applicants equally without regard to race, color, religion, sex, sexual orientation, gender identity, or national origin.

    Evolent Health intends to establish a great working environment in the Philippines and offers a competitive benefit package.

    Candidates offered a position must be able to successfully pass the background check.

  • Skills testing may be required. Employees will initially be hired by Genfinity with the expectation that they will be transferred to Evolent.
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