Senior Process Executive-Voice
Location
Secunderabad | India
Job description
Job Description
Not Applicable
Qualification :
Graduate (exclusion :
BE/BTech/MCA)
- For Medical Management Bacheloru2019s degree in Nursing or any health science related field.
- For NA High School Equiv.
Responsibility :
Business / Customer :
Data Processes :
:
- u2022 Efficiently Process predefined number of transactions as assigned with highest level of accuracy as agreed upon by the client.
- u2022 Provide highest level of customer satisfaction.
- u2022 Strive to understand and resolve issues/queries at the first instant.
- u2022 Maintain the business controls as per the requirement.
- u2022 Articulate/ communicate in a manner which is understood by clients / endusers.
- u2022 Connect & provide highest level of satisfaction to the customer.
For Member Management :
- u2022 Generate clientspecified reports relating to operations.
- u2022 Respond to data requests and other inquiries from the client.
- u2022 Release WCUM determinations to claim stakeholders following clientestablished protocols.
- u2022 Identify the medical flags in the client system.
- u2022 Provide reports and other data requests specified by the client.
- u2022 Serve as first level contact for customer complaint resolution.
- u2022 Provide reports and other data requests specified by the client.
For NA :
- u2022 Take ownership of delivery including any customer communication and handle queries / clarifications from the customer.
Voice Processes :
:
For Claims, RCM, Provider Services and Member Services :
- u2022 Make and Answer calls to and from customers/end users based on agreed time frames.
- u2022 Transfer calls involving next level of service to the appropriate department as per the given guidelines.
Project / Process :
Data Processes :
:
- u2022 Ensure to meet all Statistical, Financial and TAT metrics while processing claims.
- u2022 100% Process adherence to transaction processing timelines involving medical management processes.
- u2022 Adhere to audit compliance (Internal, Statutory Audit) of all Healthcare processes as laid out by Cognizant / the client of Cognizant.
- u2022 Ensure process guidelines are followed and met as documented.
- u2022 Set productivity /Quality benchmark.
- u2022 Adhere to shift handover processes.
- u2022 Raise process related issues / concerns on time with process and team leads.
- u2022 Record data relating to production statistics, enduser related notes, etc as appropriate.
- u2022 Stay updated with the process knowledge / changes refer to knowledge updates/ repositories to effectively process transactions.
- u2022 Adhere to security practices set by organization.
- u2022 Implement small process improvement projects.
- u2022 Provide updates and submit reports related to own area of work.
- u2022 Resolve process related queries and expedite on data requests.
- u2022 Respond to data requests.
- u2022 Maintain confidentiality of all information, policies, and procedures as required by the Health Insurance Portability and Accountability Act (HIPAA) protocols.
- u2022 Maintain acceptable levels of performance including but not limited to attendance, adherence to protocols, customer courtesy, and all other productivity and efficiency targets and objectives.
- u2022 Contribute new ideas and innovative approaches at work.
- u2022 Participate in project and organization initiatives led by the Delivery leadership.
For Medical Management :
- u2022 Identify cases eligible for medical reviews and assign these to appropriate reviewers.
- u2022 Reach out to the client for any problems identified in the cases for review.
- u2022 Adhere to Utilization Review Accreditation Commission (URAC), jurisdictional, and/or established MediCall best practice UM time frames, as appropriate.
- u2022 Adhere to federal, state, URAC, client, and established MediCall best practice WCUM time frames, as appropriate.
- u2022 Develop a complete understanding of the Medical management Procedures.
- u2022 Perform medical review assessment (MRA) on utilization of health services (eg healthcare plans, workers compensation products etc) in an accurate, efficient and timely manner while ensuring compliance with utilization management regulations and adherence to state and federal mandates.
- u2022 Provide succinct negotiable points based on the submitted medical records that identify necessary medical treatment, casually related care, response or lack of response to treatment, etc.
- u2022 Identify missing records and information that are necessary in the completion of the medical review assessment.
- u2022 Adhere to Department of Labor, state and company timeframe requirements.
- u2022 Coordinates physician reviewer referral as needed and follows up timely to obtain and deliver those results.
- u2022 Track status of all utilization management reviews in progress and follow up on all pending cases.
- u2022 Work closely with management team in the ongoing development and implementation of utilization management programs.
- u2022 Respond to inbound telephone calls pertaining to medical reviews in a timely manner, following clientestablished protocols.
- u2022 Process customer calls consistent with program specified strategies and customer satisfaction measurements to include but not limited to proper answering procedure, eg opening and closing remarks.
- u2022 Learn new methods and services as the job requires.
- u2022 Advise supervisor of any potential problems as they become evident.
- u2022 Manage assigned workload within established performance standards.
- u2022 Perform quality control on medical review assessments generated by the medical review process.
- u2022 Utilize the approved monitoring tool and updated template completion guidelines as required to compile and track performance of each associate.
- u2022 Provide feedback to the Team Leads and Manager on the performance of each associate and the team as a whole.
- u2022 Maintain and secure confidentiality of Clientu2019s data and all individually identifiable health information accessed through the clientu2019s and/or Cognizantu2019s systems.
- u2022 Coordinates with the immediate superior regarding updates in policies, procedures and process flow, and state requirements.
- u2022 Learn new protocols and systems as the job requires.
- u2022 Escalate to the immediate superior any unforeseen events or situation beyond assigned tasks and jurisdiction.
For Claims :
- u2022 Process Claims documents with zero critical errors and complete claims transaction volumes in queue within the specified TAT.
- u2022 Contribute towards creation of knowledge updates & stay updated with process knowledge / changes.
- u2022 Advice and counsel employees on benefit related issues in accordance with the Certified and classified Master Agreements and Administrative Program enabling proper and complete utilization of existing and new benefits.
- u2022 Code complex plans in the system after thoroughly analyzing the source documents.
- u2022 Benefit Plan analysis where she/he creates the source document for coders by reviewing the master agreement document.
For RCM :
- u2022 Follow up on all pending claims appropriately and initiate the next steps.
- u2022 Complete transactions for claims submissions, rejections, Payment posting as defined in SOPu2019s.
- u2022 Complete coding transactions with the required ICD, CPT and other requirements.
- u2022 Highlight global issues in the respective hospital accounts.
- u2022 Cross training on multiple process.
For Provider Services :
- u2022 Work on the difficult and complex transactions with stringent turnaround time and specifics are necessary.
- u2022 Complete missing information in provider details and update the database accordingly for first time providers and already existing provider groups in the client systems or database.
- u2022 Maintain accuracy on data procured during outreach/Fax or Email.
- u2022 Validate and update the information into the client/customer systems to remove duplicate /unwanted /expired information.
- u2022 Review and analysis of the provider application for completeness and accuracy.
- u2022 Verification of data through approved sources listed by the client.
- u2022 Data entry of updated/additional information from provider application to client system after due verification.
- u2022 Collect all pertinent information from the provider, provideru2019s malpractice insurer, National Practitioner Data Bank (NPDB) and other sources as listed by the client.
- u2022 Make outreaches to providers to collect missing.
Must Have Skills
- Credentialing&Re-credentialing
Employee Status : Full Time Employee
Shift : Day Job
Travel : No
Job Posting : Feb 29 2024
About Cognizant
Cognizant (Nasdaq-100: CTSH) is one of the world's leading professional services companies, transforming clients' business, operating and technology models for the digital era. Our unique industry-based, consultative approach helps clients envision, build and run more innovative and efficient businesses. Headquartered in the U.S., Cognizant is ranked 185 on the Fortune 500 and is consistently listed among the most admired companies in the world. Learn how Cognizant helps clients lead with digital at or follow us
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