DE030193-PHRN Claims Management Associate

myGwork - LGBTQ+ Business Community


Date: 3 weeks 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.

  • 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

Qualifications

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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