DE030193-PHRN Claims Management Associate
myGwork - LGBTQ+ Business Community
Date: 19 hours ago
City: Quezon City
Contract type: Full time
This job is with Accenture, an inclusive employer and a member of myGwork – the largest global platform for the LGBTQ+ business community. Please do not contact the recruiter directly.
SKILLS AND QUALIFICATIONS:
- ONLY THOSE APPLICANTS WHO ALREADY HAVE THE RIGHT TO LIVE AND WORK IN THIS COUNTRY ARE ELIGIBLE TO APPLY FOR THIS ROLE--- POSITION TITLE: PHRN Claims Management AssociateWORK SETUP: HybridRESPONSIBILITIES:
- Manages incoming or outgoing telephone calls, emails, and/or faxes, including triage, opening of cases and data entry into client system.
- Determines contract; verifies eligibility and benefits.
- Adhere to federal and state regulatory and/or client plan requirements and established workflows
- Obtains information from claimant or other supporting systems, emails and/or from fax. Manages claims, collection of non-clinical information needed for review from claimants and providers, utilizing scripts to screen basic and complex requests.
- Data entry of contact into client systems and route as appropriate.
- Tasks cases accurately to the correct queue.
- Performs leave follow-ups as required, including recertification of health conditions, intermittent claim tracking, Return to Work confirmation, etc.
- Update systems to accurately reflect leave status and ensure appropriate documentation exists.
- Conducts outbound scripted calls to claimants and providers to request for clinical information.
- Review and assessment of primarily complex illness and injury claims.
- Identify restrictions and limitations based on physiological, psychological, and social factors to assist claim management staff in their claim handling activities.
- Validate the medical necessity of limitations and/or restrictions with clear rationale.
- Provide claim management staff with medical insight and education to assist them in determining appropriate determination.
- Discuss medical issues and documents outcomes of discussions.
- Uses available resources to understand contractual and regulatory compliance requirements and reports suspected compliance issues on the day of discovery to a Team Lead, Manager, and/or the Compliance Department.
- Responsible for reporting known or suspected data disclosures or fraud on the day of discovery to a Team Lead.OTHERS:Project Shift Schedule: Night ShiftProject Rest Day: Weekends OffProject/Team Location: Quezon City, Gateway Tower 2
SKILLS AND QUALIFICATIONS:
- No work experience required
- Holds active PHRN licensure
- End-to-end claims processing or clinical work experience is good to have
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