Health Clinical Services Senior Manager
Gratitude IncHealth Clinical Services Senior Manager
Job Description
Key Skills
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Responsibilities:
Oversees staff whose teams’ primary duties may include, but are not limited to:
• Conducts pre-service, concurrent, retrospective, out-of-network, and appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.
• Service requests may be from inbound calls and facsimile.
• Outbound calls to the provider may be required to gather additional information that may be needed.
• Other staff responsibilities may include review and analysis of post-service claims utilizing the member’s benefit contract and health plan guidelines.
• Completes review of pended claims post-service for either Medical Necessity or Contractual Reviews.
SKILL AND QUALIFICATIONS:
• At least 12 years of relevant experience and 10 years of supervisory experience
• Holds current and unrestricted US Registered Nurse license. No state-specific RN licensure required.
• BPO experience should be any account (Health account experience is only a plus, but not required)
• Work Background/Experience in General: Must be open to BPO & Non-BPO Experience
• Open for those applicants who are currently in Philippines and already have the right to live and work in this country are eligible for this role
Role
US Registered Nurse
Timings
Night Shift (Permanent)
Industry
IT-Software / Software Services
Work Mode
Work from office
Process
Voice
Functional Area
ITES / BPO / Customer Service
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