Clinical Team Leader - Clinical Appeals - CONCENTRIX BRIDGETOWNE (URGENT)

Join the Leading Global Provider of CX and Tech Services and seize this moment to #JoinConcentrix!

Essential Duties and Responsibilities:

• Review and Assess Appeal(s) Case(s) Submitted by our Member(s), Provider(s), as well as Authorized Representative(s) for Medicare Part C Service(s), Evaluate the Clinical Appropriateness of Initial Determination(s) Based on Medical Necessity, Benefit Coverage, and CMS Guideline(s)
• Document Appeal Decision(s) Clearly, Accurately, and in Compliance with CMS Requirement(s) and Client Specific Protocol(s), Ensure Timely Processing of Appeal Case(s) within the Regulatory Turnaround Time(s) Set by CMS, Collaborate with Medical Director(s), Case Reviewer(s), and Internal Department(s) to Gather Required Clinical Information for Appeal Resolution
• Draft Clear and Compliant Member and Provider Correspondence Letter(s) Based on Appeal Outcome(s), Support the Appeals Quality Program by Participating in Self-Audit(s) and Implementing Feedback for Continuous Improvement, Uphold High Level(s) of Data Privacy, Confidentiality, and HIPAA Compliance Standard(s), Participate in Ongoing Training, Calibration, and Performance Discussion(s) to Maintain Clinical and Regulatory Knowledge, Escalate Complex or High-Risk Case(s) to Medical Director(s) or Appeals Leadership as Required
• Conduct Regular One-on-One's with Direct Report(s) to Review Individual Performance and Offer Ongoing Developmental Support - Manage Performance of Direct Report(s) Including Planning and Assigning Work for Staff in Accordance with the Organization's Policies and Applicable Legal Requirement(s), Provide Leadership and Guidance to Direct Report(s) to Ensure Consistent Administration of Company Policies and Standard(s), Define and Implement Any Corrective Action(s) Needed to Meet Required Operational Performance

Minimum Hiring Qualifications:

• Active Philippine Registered Nurse (PHRN) with License Required - 1 Year(s) Minimum of Clinical Nursing Experience (Hospital, Clinic, or Managed Care Setting) with 6 Month(s) Minimum of Clinical Process Outsourcing Experience and Background Handling Clinical Role(s) Focusing on Clinical Appeals and Utilization Management and Other Related Function(s)
• Experience as a Team Lead or Supervisor in a Similar Support Environment - Other Related Role(s) Exposed to Related Function(s) are also Considered
• Demonstrates Excellent Verbal and Written Communication Skills, Strong Attention to Detail and Case Documentation Practice(s), Ability to Manage Multiple Case(s) and Meet Regulatory Turnaround Time(s) Under Pressure, Proficient in Basic Microsoft Office Application(s) such as Word, Excel, and Outlook, Willing to Work on Flexible Schedule(s) Including US Hour(s) and Holiday(s)
• Strong Clinical Knowledge Particularly in Medical Necessity Review and Interpretation of Clinical Documentation(s), Good Knowledge and Understanding of Different Healthcare Insurance Process(es), Appeals, Grievances, and Utilization Management is Preferred
• Preferred Qualification(s): Experience Handling Medicare Part C or US-Based Appeals Case(s), Familiarity with CMS Guideline(s), NCQA Standard(s), or URAC Regulation(s), Experience in Using Appeals Management Platform(s) (VAM and Salesforce Health Cloud)

Get Hired and Enjoy the Following:

• Interact/Collaborate and Learn from Industry Experts
• Multiple Opportunities for Learning and Development
• Enjoy a Fun - and Competitive Working Environment

Work Location: Tera Tower, Bridgetowne, Quezon City