Roles & Responsibilities: Manage inbound & outbound calls from US providers, pharmacies, and members regarding benefits or claim denials. Handle US Medical/PBM denied claims and Utilization Management (PA, Appeals, etc.). Manage RCM cycle for patient financial encounters. Evaluate documents to ensure accurate claim information. Resolve customer queries and complaints professionally. Adhere to call center scripts, maintain quality standards, and prepare reports. Requirements: 23 years of US Healthcare voice process experience. Excellent communication skills. Comfortable with rotational shifts (247) and working on Indian holidays. Strong knowledge of claims handling and CRM systems . Customer-focused, adaptable, with good problem-solving skills. Must be willing to work in a voice process .
Role & responsibilities Experience : 1- 6 years of US Calling Experience. Responsibilities: Manage Inbound & Outbound calls and customer service enquiries, in this profile specifically agent will be answering an inbound calls which they will receive from the providers/pharmacies/members to seek assistance on benefits or on claim denials. US Medical/PBM denied Claims Handling process. Utilization Management handling including PA, Appeals, etc. RCM cycle that is used to manage the financial cycle of a patients encounter. Management and resolve customer complaints Identifying customers needs, clarify information, research every issue and providing solutions Following call centre scripts when handling different topics Work with the team to resolve issues with good aptitude Maintain and prepare activity reports. Maintains and improves quality results by adhering to standards and guidelines, recommending improved procedures Requirements: Previous experience in US Voice Process Should be comfortable with rotational shifts and offs. Should be comfortable with working on Indian Holidays. Should be well versed with end to end claims handling process. Strong phone and verbal communication skills along with active listening Familiarity with CRM systems and practices Customer focus and adaptability to different personality types Ability to multi-task, set priorities and manage time effectively Mandatory Skills/Experience: Excellent communication skills (written and verbal). American accent would be preferable. Should be comfortable with rotational shifts and offs. Should be comfortable with working on Indian Holidays. Candidates must be willing to work in Voice process.
Job Title : Clinical Coordinator (Health Plans) Job Type: Full-Time Job Location: Noida, India Department : Clinical Job Summary : The Clinical Coordinator has a well-developed knowledge and skill set in utilization management (UM), medical necessity, and care coordination. This individual is responsible for performing a variety of prospective, concurrent, and retrospective UM-related activities. These operations are primarily focused on utilization management and communications. The coordinator works with clinical team members, such as pharmacists, nurses, and pharmacy technicians, to ensure that clinical activities are completed according to accreditation and regulatory requirements. Ensure timely, customer focused in delivering quality care. Job Responsibilities (but not limited to): The primary responsibilities involve assisting by coordinating activities of medical utilization management team in configuring, testing, and maintaining systems and processes to deliver quality care. Clinical Coordination Performs prospective, concurrent, and retrospective medical necessity reviews for healthcare products and services utilizing appropriate clinical criteria and/or evidence-based guidelines. Ensures regulatory and/or accreditation guidelines are met for timeliness of medical necessity reviews. Verifies accuracy of codes and services and applies them accurately with appropriate documentation. Communicates member, provider, and facility notifications, citing clinical criteria and Medical Director denial rationale, when indicated. Process incoming and outgoing referrals, and prior authorizations, including intake, notification, and census roles. Assist the clinical staff with setting up documents/triage cases for Clinical Coverage Review. Handle resolution/inquiries from members and/or providers. Utilization Management Analysis & Testing Evaluates, coordinates, manages, and documents all UM-related activities. Maintains a current knowledge of medical necessity criteria and UM-related policies and procedures. Participates in the monitoring of the effectiveness and outcomes of the UM program. Comply with all regulatory and accreditation standards related to utilization management and/or case management. Help with Utilization management reviews and testing the systems to make sure upgrades went well, etc. Assists with developing communications (e.g., letters, forms) and configuration within the platforms in compliance with state and federal requirements. Provides support for internal and external audits. Stays abreast of new regulations to ensure regulatory and compliance applicable to clinical operations. Assist in resolving incoming appeals, complaints, and grievances. Qualifications: Education and/or Training: Bachelors degree in any medical education. (Essential) Post-Graduation in healthcare related field or MBA (Healthcare or equivalent degree). (Desired) Professional Experience: Minimum two (2) years of prior experience in utilization management, clinical coordination related to health plans or case management is preferred. Knowledge of US Healthcare System; specifically, Medicare is highly preferred. Experience with Medicare Advantage plans with knowledge of CMS guidance/regulations is preferred. Must have a regard for confidential data and adherence to corporate compliance policy. 2. Licenses/Certifications: Utilization Management or Case Management certification is preferred. (Desired) 3. Specialized Skills: Employ effective use of knowledge and critical thinking skills. Apply effective time and project management skills. Strong interpersonal skills Performance management skills Results driven individual 4. Technical Skills: Strong PC skills; MS Word, Excel, Access, and Power Point. 5. Additional Considerations: Applicants must be able to pass a background investigation as all offers are pending a successful completion of background check per the company policy.
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