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Process Specialist

3 months ago

Pune, Maharashtra, India Cognizant Full time

Not Applicable

Qualification:

Graduate (exclusion:

BE/BTech/MCA
  • 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:

Ensure minimum transactions are routed to the client and all procedural queries are handled in-house

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

  • UiPath Developer
  • Clearing House
  • Enrollment