DE032705-Health Clinical Svcs Specialist

ONLY THOSE APPLICANTS WHO ALREADY HAVE THE RIGHT TO LIVE AND WORK IN THIS COUNTRY ARE ELIGIBLE TO APPLY FOR THIS ROLE---

WORK SETUP: Return to Office

• Oversees staff whose 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 (UM service requests are received from inbound calls and facsimile. Outbound calls to the provider may be required to gather additional information that may be needed)
• Responsible for maintaining contractual, regulatory and accreditation compliance by knowing, understanding, correctly interpreting, and accurately applying requirements, regulations and standards. Reports suspected or confirmed issues on the same day of discovery to the manager and/or the Compliance Department.
• Responsible for ensuring Associate understanding of contractual, regulatory and accreditation requirements and reporting immediately all suspected or confirmed issues or concerns to a manager and/or the Compliance Department.
• Responsible for ensuring that all clinical USRN associates maintain active, documented licensure while working in production. Removes clinical associates from production when active USRN licensure is not verified by PMO team. . Reports instances of expired or lapsed licensure on the date of discovery to the PMO team and to the Compliance Department.
• Facilitate accreditation by participating and /or conducting in audits as needed.
• Provides leadership, mentoring, and supervision of staff.
• Responsible for reporting known or suspected data breaches on the day of discovery to the Compliance Department and for conducting a follow-up investigation as needed.
• Perform Root Cause Analysis (RCA) for performance deviations and implement improvement plans and associate coaching as needed.
• Study and analyze VOC (Voice of customer) trend and customer feedback and work towards improving performance
• Performance Management
• Performs regular performance management steps in managing team performance
• Responsible for ongoing staff performance tracking; daily, weekly and month to date.
• Schedules 1x1 coaching sessions as needed, discusses with the associate goals and objectives required, documents all discussions, and sets time frame to meet goals and provides timely follow-up with the associate.
• Derives data from client system and looks at current inventory levels to establish action items
• Reviews quality data (client audits and desk level audits) and analyzes root causes with team for action planning
• Oversees goal setting or all associates at the start of the fiscal year in compliance with the annual review process.

Project/Team Location: Quezon Gateway Tower 2