Health Operations Associate

---ONLY THOSE APPLICANTS WHO ALREADY HAVE THE RIGHT TO LIVE AND WORK IN THIS COUNTRY ARE ELIGIBLE TO APPLY FOR THIS ROLE--- POSITION TITLE: Health Operations Associate WORK SETUP: Return to Office RESPONSIBILITIES: • Determines contract; verifies eligibility and benefits. • Conducts a thorough provider radius search in client system and follows up with provider on referrals given. • Checks benefits for facility-based treatment. • Obtains intake (demographic) information from callers, e-Reviews, and/or from faxes. Processes incoming requests, collection of non-clinical information needed for review from providers, utilizing scripts to screen basic and complex requests for pre-certification and/or prior authorization. • Performs data entry of contact into client systems and routes as appropriate. • Matches fax/clinical records with appropriate case. • Consolidates inputs for approval. • Generates the needed letters as directed by the client and/or outlined in the client’s procedure manual. • Assigns cases/activities and work within the client’s system to facilitate workflow and productivity goals. • Refers cases requiring clinical review to a nurse reviewer. Performs case checks and reviews to ensure case creation is complete and correct for the clinician • Tasks cases accurately to the correct queue. • Conducts outbound scripted calls to providers to request clinical information as directed by the clinician. • Conducts outbound scripted calls to providers to complete approval notification process as directed by the clinician. • Performs Daily Task list maintenance activities under the direction of the Team Lead/Operations Manager and as per customer workflow. • Provides administrative support to Nurse Reviewer via case preparation, phone number verification, medical record requests and verbal call out approval notifications. • Provides administrative support of post service claims utilizing the member’s benefit contract and health plan guidelines. • Performs administrative tasks and work as directed by clinician or Team Lead/Operations.? Consults clinician and Team Lead/Operations Manager at a time and appropriately. OTHERS: Project Shift Schedule: Night Shift Project Rest Day: Weekends Off Project/Team Location: Quezon Gateway Tower 2SKILL AND QUALIFICATIONS: • Graduate of any college degree or High School Diploma with 6 months’ BPO work experience • At minimum 6 months of work experience. • Excellent written and verbal communication skills in English • For voice accounts, must pass US CEFR B2 level or Versant score of 58 or any language proficiency equivalence. • Proficiency in basic computer knowledge with the ability to learn additional computer programs. • Experience and Skills Preferred • Knowledge of utilization management process and ability to interpret and apply member contracts, and member benefits. • Prior clinical BPO experience • Strong customer service focus • Ability to empathize. • Prioritizing customer needs • Listening, patience & action oriented • Good understanding of phone etiquette • Claim reviews/audit experience. • Experience in United States medical or insurance field • Knowledge of ICD-9 and ICD-10 and CPT codes • Experience in medical or insurance field Working Conditions • Cyclical work shift including work hours at night; able and willing to work U.S. time and as needed. • Overtime and On-Call may be required to meet the needs of the client/business. • Employees are able to travel to and work/train in the office as required and requested by management. • Additional tasks may be assigned by your Immediate Supervisor/Project Manager. • Holidays are observed in compliance with client-specific contracts or statements of work (SOW). • For Remote/Work from Home Employees: Ability to work independently

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