• Senior process executivevoice Jobs in Pune,India - 25638673

  • Cognizant
  • Save Job
  • 1 - 4 Years
  • Posted : above 1 month

Job Description:

Not Applicable


Graduate (exclusion

BE/BTech/MCA) For Medical Management Bachelor s degree in Nursing or any health science related field
For NA High School Equiv


Business / Customer

Data Processes

Efficiently Process predefined 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 / endusers
Connect & provide highest level of satisfaction to the customer

For Member Management

Generate clientspecified reports relating to operations
Respond to data requests and other inquiries from the client
Release WCUM determinations to claim stakeholders following clientestablished 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, enduser 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 clientestablished 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 Client s data and all individually identifiable health information accessed through the client s and/or Cognizant s 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


Follow up on all pending claims appropriately and initiate the next steps
Complete transactions for claims submissions, rejections, Payment posting as defined in SOP s
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, provider s malpractice insurer, National Practitioner Data Bank (NPDB) and other sources as listed by the client
Make outreaches to providers to collect missing,
Domain Skills
SNoPrimary SkillProficiency Level *Rqrd/Dsrd 1 Customer Service-Healthcare NA Required 2 Billing NA Required

* Proficiency Legends
Proficiency LevelGeneric Reference PL1 The associate has basic awareness and comprehension of the skill and is in the process of acquiring this skill through various channels PL2 The associate possesses working knowledge of the skill, and can actively and independently apply this skill in engagements and projects PL3 The associate has comprehensive, in-depth and specialized knowledge of the skill She / he has extensively demonstrated successful application of the skill in engagements or projects PL4 The associate can function as a subject matter expert for this skill The associate is capable of analyzing, evaluating and synthesizing solutions using the skill

Profile Summary:

Employment Type : Full Time
Industry : IT - Software
Salary : Not Disclosed
Deadline : 08th Jul 2020

Key Skills:

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