**Not Applicable**
**Qualification**:
**Graduate (exclusion**:
BE/BTech/MCA)
- For Medical Management Bachelor's degree in Nursing or any health science related field.
- For NA High School Equiv.
**Responsibility**:
**Business / Customer**:
**Data Processes**:
- Provide highest level of customer satisfaction.
- Strive to understand and resolve issues/queries at the first instance.
- Maintain the business controls as per the requirement.
**For NA, Medical Management and Benefit Coding**:
- Respond to data requests and generate clientspecified reports in a timely manner.
- Articulate/ communicate in a manner which is understood by clients / endusers.
**Claims, RCM and Member Services**:
- Efficiently Process predefined number of claims / enrollment as assigned with highest level of accuracy as agreed upon by the client.
**For RCM**:
- Escalating the issues recieved in different batches.
- Supporting the team to achieve the SLA and TAT associated with Correspondence, Payments, PIA, and Write off.
- Delivering the quality metrics as defined by Customers.
**Voice Processes**:
**For Claims, RCM and Member Services**:
- Make and Answer calls to and from customers/end users based on agreed time frames.
- Transfer calls involving next level of service to the appropriate department as per the given guidelines.
**Project / Process**:
- Develop a complete understanding of the Procedures.
- Complete transactions for data preparation, submissions, etc as defined in SOP's.
- 100% Process adherence to transaction processing timelines.
- Adhere to audit compliance ( SAS 70, SOX, Statutory Audit) of all processes as laid out in process documentation.
- Ensure process guidelines are followed and met as documented.
- Set productivity /Quality benchmark.
- Adhere to shift handover processes.
- Raise process related issues / concerns on time with process and team leads.
- Ensure to meet all Statistical, Financial and TAT metrics.
- Stay updated with the process knowledge / changes refer to knowledge updates/ repositories to effectively process transactions.
- Adhere to security practices set by organization.
- Provide updates and submit reports related to own area of work.
- Complete transaction / calls volumes in queue within specified Turn Around Time.
- Respond to data requests.
- Perform administrative duties which includes maintaining accurate records of information regarding received claims/treatment requests.
- Record data relating to production statistics, enduser related notes, etc as appropriate.
- Maintain confidentiality of all information, policies, and procedures as required by the Health Insurance Portability and Accountability Act (HIPAA) protocols.
- Raise process related issues/concerns to team leads/manager.
- Adhere to federal, state, URAC, clientspecified, and established best practices regarding utilization management.
- Adhere to program quality standards and maintain acceptable levels of performance, including but not limited to attendance, adherence to protocols, customer courtesy, and all other productivity and efficiency targets and objectives.
- Continuous contribution to process excellence/improvement.
- Participate in project and organization initiatives led by the Delivery leadership.
**For Medical Management**:
- Receive, login and file a variety of reports, client charts, client interactions and other documents as needed in the account.
- Efficiently prepare and/or assign a predefined number of cases/transactions with highest accuracy.
- Prescreen a claim/treatment request for completeness and determine if this is appropriate for further processing.
- Sort, upload and assign the claim/treatment request to a case administrator, nurse reviewer or physician reviewer.
- Follow up on all pending claims appropriately and initiate the next steps.
**For Claims**:
- Input enrollment/change data in a timely manner to coincide with transmittal to vendors and district payroll.
- Process claims documents with zero critical errors.
- Manage benefits documentation by assembling benefit packets, filing benefits paperwork.
- Works on Blue Exchange, Benefit Narratives and related line of businesses.
**For RCM**:
- Follow up on all pending claims appropriately and initiate the next steps.
- Complete transactions for claims submissions, rejections, Payment posting as defined in SOP's.
- Complete coding transactions with the required ICD, CPT and other requirements.
- Respond to data requests.
- Process claims, charges and coding with zero critical errors.
**For Provider Services**:
- Perform verification of data through approved sources listed by the client.
- Collect all pertinent information from the provider, provider's malpractice insurer, National Practitioner Data Bank (NPDB) and other sources as listed by the client.
- Make outreaches to providers to collect missing/outdated information.
- Manage Inventory and work on files that require multiple follow ups with the provider.
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