Not Applicable

Qualification:
Graduate (exclusion:
BE/BTech/MCA) For Medical Management Bachelors degree in Nursing or any health science related field.
For NA High School Equiv.

Responsibility:
Business / Customer:

Data Processes:
:
Efficiently Process pre-defined number of transactions as assigned with highest level of accuracy as agreed upon by the client.
Provide highest level of customer satisfaction.
Strive to understand and resolve issues/queries at the first instant.
Maintain the business controls as per the requirement.
Articulate/ communicate in a manner which is understood by clients / end-users.
Connect & provide highest level of satisfaction to the customer.

For Member Management: Generate client-specified reports relating to operations.
Respond to data requests and other inquiries from the client.
Release WCUM determinations to claim stakeholders following client-established protocols.
Identify the medical flags in the client system.
Provide reports and other data requests specified by the client.
Serve as first level contact for customer complaint resolution.
Provide reports and other data requests specified by the client.

For NA: 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: Make and Answer calls to and from customers/end users based on agreed time frames.
Transfer calls involving next level of service to the appropriate department as per the given guidelines.

Project / Process:

Data Processes:
:
Ensure to meet all Statistical, Financial and TAT metrics while processing claims.
100% Process adherence to transaction processing timelines involving medical management processes.
Adhere to audit compliance (Internal, Statutory Audit) of all Healthcare processes as laid out by Cognizant / the client of Cognizant .
Ensure process guidelines are followed and met as documented.
Set productivity /Quality benchmark.
Adhere to shift handover processes.
Raise process related issues / concerns on time with process and team leads.
Record data relating to production statistics, end-user related notes, etc as appropriate .
Stay updated with the process knowledge / changes – refer to knowledge updates/ repositories to effectively process transactions.
Adhere to security practices set by organization.
Implement small process improvement projects.
Provide updates and submit reports related to own area of work.
Resolve process related queries and expedite on data requests.
Respond to data requests.
Maintain confidentiality of all information, policies, and procedures as required by the Health Insurance Portability and Accountability Act (HIPAA) protocols.
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.
Contribute new ideas and innovative approaches at work.
Participate in project and organization initiatives led by the Delivery leadership.

For Medical Management: Identify cases eligible for medical reviews and assign these to appropriate reviewers.
Reach out to the client for any problems identified in the cases for review.
Adhere to Utilization Review Accreditation Commission (URAC), jurisdictional, and/or established MediCall best practice UM time frames, as appropriate.
Adhere to federal, state, URAC, client, and established MediCall best practice WCUM time frames, as appropriate.
Develop a complete understanding of the Medical management Procedures.
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 .
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.
Identify missing records and information that are necessary in the completion of the medical review assessment.
Adhere to Department of Labor, state and company timeframe requirements .
Coordinates physician reviewer referral as needed and follows up timely to obtain and deliver those results.
Track status of all utilization management reviews in progress and follow up on all pending cases.
Work closely with management team in the ongoing development and implementation of utilization management programs.
Respond to inbound telephone calls pertaining to medical reviews in a timely manner, following client-established protocols.
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.
Learn new methods and services as the job requires.
Advise supervisor of any potential problems as they become evident.
Manage assigned workload within established performance standards.
Perform quality control on medical review assessments generated by the medical review process.
Utilize the approved monitoring tool and updated template completion guidelines as required to compile and track performance of each associate.
Provide feedback to the Team Leads and Manager on the performance of each associate and the team as a whole.
Maintain and secure confidentiality of Clients data and all individually identifiable health information accessed through the clients and/or Cognizants systems.
Coordinates with the immediate superior regarding updates in policies, procedures and process flow, and state requirements.
Learn new protocols and systems as the job requires.
Escalate to the immediate superior any unforeseen events or situation beyond assigned tasks and jurisdiction.

For Claims: Process Claims documents with zero critical errors and complete claims transaction volumes in queue within the specified TAT .
Contribute towards creation of knowledge updates & stay updated with process knowledge / changes.
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.
Code complex plans in the system after thoroughly analyzing the source documents.
Benefit Plan analysis where she/he creates the source document for coders by reviewing the master agreement document.

For RCM: Follow up on all pending claims appropriately and initiate the next steps.
Complete transactions for claims submissions, rejections, Payment posting as defined in SOPs.
Complete coding transactions with the required ICD, CPT and other requirements.
Highlight global issues in the respective hospital accounts.
Cross training on multiple process.

For Provider Services: Work on the difficult and complex transactions with stringent turnaround time and specifics are necessary.
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 .
Maintain accuracy on data procured during outreach/Fax or Email.
Validate and update the information into the client/customer systems to remove duplicate /unwanted /expired information.
Review and analysis of the provider application for completeness and accuracy.
Verification of data through approved sources listed by the client.
Data entry of updated/additional information from provider application to client system after due verification.
Collect all pertinent information from the provider, providers malpractice insurer, National Practitioner Data Bank (NPDB) and other sources as listed by the client.
Make outreaches to providers to collect missing.


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