Process Specialist

Not Applicable

Qualification:

Graduate (exclusion:

• For Medical Management College/ University degree holder.

• For NA High School/Equiv, Associates Degree preferred or equiv work experience.

Responsibility:

'Business / Customer:

Data Processes:

For NA, Claims, RCM, Provider Services and Member Services:

• • Focus on enabling quality deliverables and enhancing customer satisfaction.

• • Provide regular and meaningful updates and communicates to client, stakeholders and Team lead/management.

• • Interact with customers (internal / external) to meet process deliverables.

• • Manage and resolve escalations and issues raised by customers.

• • Single point of contact for all knowledge related issues.

For Claims, RCM and Provider Services:

• • Data accuracy with respect to client requirements.

• • All required data to complete the provider database or provider profile needs to be captured with 100% accuracy in the client applications.

• • Need to work on complex state mandate applications, where the timelines are very stringent.

• • Minimize rework by developing First Time Right culture.

• • Generate process improvement ideas for better productivity, accuracy & turnaround time.

• • Participate as potential seed resources for staffing new engagements.

• • Perform root cause analysis on the errors made by the team members.

• • Handles Supervisor Calls and escalation calls.

For Medical Management and Provider Services:

• • Check and update all missing information from the requests as required by customer/client.

• • Monitor product updates and communicate product inquiries with the client.

• Query Management:

For NA:

• • Report performance dashboards on a periodic basis to the customer stakeholders.

• • Engage with Customer and drive status report meetings.

Voice Processes:

For Claims, RCM and Member Services:

• • Effectively communicate information on products/services or trouble shoot issues within the specified time frames as agreed upon with the client,.

• • In a manner that is understandable by the end user/ customer.

• • Connect with the customer & provide highest level of customer satisfaction.

Project / Process:

Data Processes:

:

• • Perform transactions as per defined guidelines.

• • Resolve process related queries within defined timelines.

• • Provide periodic status reports to the team leader on performance, status and any escalations.

• • Adhere to defined support and quality processes as per the guidelines.

• • Maintain proper documentation of all the transactions.

• • Perform quality assurance review wherever applicable basis the process requirement.

• • Assist with audits and maintain strict level of confidentiality on all matters pertaining to provider and /or payers.

• • Prepare professional communication, emails, letters to providers.

• • Meet deadlines and ensure good follow in call and email tracking.

• • Ensure that quality, efficiency and productivity standards and targets are met.

• • Review productivity with each associate and recommends followup training if necessary.

• • Analyze areas for improvement with an objective to meet program metrics.

• • Report regular error feedback.

• • Performs other duties as may be assigned.

• • Focus on enabling quality deliverables and enhancing customer satisfaction.

• • Provide regular and meaningful updates and communicates to client, stakeholders and Team lead/management.

• • Participate as potential seed resources for staffing new engagements.

• • Perform root cause analysis on the errors made by the team members.

• • Minimize rework by developing First Time Right culture.

• • Identify knowledge gaps and provides inputs to the training teams.

• • Act as Internal Auditor for the process auditing the domainspecific metric.

• • Take Initiatives to improve quality rankings and completing assignments on time.

• • Respond to queries raised by the team and provide appropriate feedbacks.

• • Participate in project and organization initiatives led by the Delivery leadership.

• • Contribute new ideas and innovative approaches at work.

For Medical Management:

• • Assist the associates in performing their tasks as per client, state and/or federal protocols as well as other related guidelines.

• • Ensures that associates are informed and updated on changes in state rules, regulations and client protocols.

• • Under the direction Team Lead/Team Manager, act as a resource person for specific regulations and protocols, to properly address issues and concerns on medical review process.

• • Act as frontline in providing product updates and answering process related questions from process executives and senior process executives.

• • Take charge of the operations in the absence Team Lead / Team Manager.

• • Maintain acceptable levels of performance including but not limited to attendance, adherence, customer courtesy, and all other productivity and efficiency targets and objective.

• • Monitor compliance of associates to established federal, state, URAC, client and protocols.

• • Keep track of turnaround time of specific state reviews and coordinates with the process executives and senior process executives to facilitate release of medical review assessments on time.

• • Report to the Team Lead/ Supervisor/ Manager on state review statistics, issues encountered complaints, etc and escalate unresolved issues as appropriate.

• • Oversee the work of new hires and continuous coaching of the program’s staff with the assistance of the Team Lead.

• • Complete a QC report and coach Nurse Reviewer/s regarding corrections and/or suggestions made in their review.

• • Work closely with the Program Trainer in establishing and maintaining Program Manuals.

For Claims:

• • Active participation in the process/knowledge transitions from business to Cognizant center.

• • Successful client certification as Process trainer (offshore) and subsequent Offshore knowledge transfer.

• • Responsible for review and updation of domain specifics SPOC for all queries before it is put forward to the client and create a repository of FAQs.

• • Ensure any updates in state mandates, policy & procedures would reach the operations team in a timely fashion.

• • Assist associates in processing tricky and high value transactions.

• • Deliver and validate clientspecific metric deliverables.

• • Responsible for claims adjudicated in a day.

• • Adjudication of claims with zero critical errors Responsible for assisting with online research projects for claim and litigation matters.

• • Responsible for preparing litigation files for archiving.

• • Responsible for assisting with collections This includes payment processing, record keeping, correspondence composition, and damage invoice composition.

• • Work effectively in team environment to coordinate all credentialing processes (ie Third party verification groups wherever applicable basis the process requirement).

• • Support the floor on queries related to complex Benefit plans and Benefit plan analysis.

• • Lead the daily huddle related to knowledge management.

• • 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.

• • Continuous contribution to process excellence/improvement.

• • Perform task estimation.

• guide the service analyst on estimation.

For RCM:

• '• Perform quality assurance review on completed credentialing files.

• • Responsible for the inventory of the respective hospital accounts and deliver the SLA parameters.

• • Responsible for the agents working in the respective hospital accounts.

• • Develop Provider Directory with accurate details of providers.

• • Collect and verify all demographic information from the provider through different sources as deemed appropriate.

• • Verify all education & hospital affiliations information of the providers.

• • Receive and process provider database on a regular basis.

• • Tracks progress of outstanding verifications from Schools and Hospitals.

• • Works effectively in.

Must Have Skills

• Benefits Configuration

• Plan Benefits