DE033452-Health Operations Associate

---ONLY THOSE APPLICANTS WHO ALREADY HAVE THE RIGHT TO LIVE AND WORK IN THIS COUNTRY ARE ELIGIBLE TO APPLY FOR THIS ROLE--- POSITION TITLE: Health Operations Associate WORK SETUP: Return to Office RESPONSIBILITIES: • Determines contract; verifies eligibility and benefits. • Conducts a thorough provider radius search in client system and follows up with provider on referrals given. • Checks benefits for facility-based treatment. • Obtains intake (demographic) information from callers, e-Reviews, and/or from faxes. Processes incoming requests, collection of non-clinical information needed for review from providers, utilizing scripts to screen basic and complex requests for pre-certification and/or prior authorization. • Performs data entry of contact into client systems and routes as appropriate. • Matches fax/clinical records with appropriate case. • Consolidates inputs for approval. • Generates the needed letters as directed by the client and/or outlined in the client’s procedure manual. • Assigns cases/activities and work within the client’s system to facilitate workflow and productivity goals. • Refers cases requiring clinical review to a nurse reviewer. Performs case checks and reviews to ensure case creation is complete and correct for the clinician • Tasks cases accurately to the correct queue. • Conducts outbound scripted calls to providers to request clinical information as directed by the clinician. • Conducts outbound scripted calls to providers to complete approval notification process as directed by the clinician. • Performs Daily Task list maintenance activities under the direction of the Team Lead/Operations Manager and as per customer workflow. • Provides administrative support to Nurse Reviewer via case preparation, phone number verification, medical record requests and verbal call out approval notifications. • Provides administrative support of post service claims utilizing the member’s benefit contract and health plan guidelines. • Performs administrative tasks and work as directed by clinician or Team Lead/Operations.? Consults clinician and Team Lead/Operations Manager at a time and appropriately. OTHERS: Project Shift Schedule: Night Shift Project Rest Day: Weekends Off Project/Team Location: Quezon Gateway Tower 2 SKILL AND QUALIFICATIONS: • Graduate of any college degree or High School Diploma with 6 months’ BPO work experience • At minimum 6 months of work experience. • Excellent written and verbal communication skills in English • For voice accounts, must pass US CEFR B2 level or Versant score of 58 or any language proficiency equivalence. • Proficiency in basic computer knowledge with the ability to learn additional computer programs. • Experience and Skills Preferred • Knowledge of utilization management process and ability to interpret and apply member contracts, and member benefits. • Prior clinical BPO experience • Strong customer service focus • Ability to empathize. • Prioritizing customer needs • Listening, patience & action oriented • Good understanding of phone etiquette • Claim reviews/audit experience. • Experience in United States medical or insurance field • Knowledge of ICD-9 and ICD-10 and CPT codes • Experience in medical or insurance field Working Conditions • Cyclical work shift including work hours at night; able and willing to work U.S. time and as needed. • Overtime and On-Call may be required to meet the needs of the client/business. • Employees are able to travel to and work/train in the office as required and requested by management. • Additional tasks may be assigned by your Immediate Supervisor/Project Manager. • Holidays are observed in compliance with client-specific contracts or statements of work (SOW). • For Remote/Work from Home Employees: Ability to work independently About Accenture Accenture is a leading global professional services company that helps the world’s leading businesses, governments and other organizations build their digital core, optimize their operations, accelerate revenue growth and enhance citizen services—creating tangible value at speed and scale. We are a talent- and innovation-led company with approximately 791,000 people serving clients in more than 120 countries. Technology is at the core of change today, and we are one of the world’s leaders in helping drive that change, with strong ecosystem relationships. We combine our strength in technology and leadership in cloud, data and AI with unmatched industry experience, functional expertise and global delivery capability. Our broad range of services, solutions and assets across Strategy & Consulting, Technology, Operations, Industry X and Song, together with our culture of shared success and commitment to creating 360° value, enable us to help our clients reinvent and build trusted, lasting relationships. We measure our success by the 360° value we create for our clients, each other, our shareholders, partners and communities. Visit us at Equal Employment Opportunity Statement We believe that no one should be discriminated against because of their differences. All employment decisions shall be made without regard to age, race, creed, color, religion, sex, national origin, ancestry, disability status, military veteran status, sexual orientation, gender identity or expression, genetic information, marital status, citizenship status or any other basis as protected by applicable law. Our rich diversity makes us more innovative, more competitive, and more creative, which helps us better serve our clients and our communities.