**Not Applicable**
**Qualification**:
Graduate /Post Graduate - preferably MBA graduates Knowledge of CRM tools & MS office tools
- For Medical Management and Provider Services Bachelor's Degree in Nursing (BSN).
- For Philippines 34 year college degree preferably related to medical field (as mandated by the project).
- For NA High School/Equiv, Associates Degree preferred or equiv work experience.
**Responsibility**:
**Business / Customer**:
- Certify controls laid down by the business to ensure successful audit by client and external party.
- Interact with customers (internal / external) and keep stakeholders appraised of the process performance.
- Create status reports for customers (internal/external).
- Manage and resolve escalations and issues raised by customers and process specialists.
- Ensure adherence to Quality norms and procedures.
- Identify & drive opportunities not limited to Cost Optimization and Process Excellence to enhance service delivery.
- Provide client/process related MI reports.
- Interface with the management both in terms of cascading messages from senior management and putting into practice strategy or modifications required for the process based on decisions taken.
- Identify & drive opportunities to enhance customer experience.
- Anticipate issues and needs of the customer related to the project and address them proactively.
- thereby help achieve CSS targets.
**For Claims, Medical Management & Provider Services**:
- Communicate with the client counterpart on a daytoday basis on daily scorecards.
**For NA TM**:
- Participate in Customer review / governance meetings to discuss on Service performance, project issues and improvement opportunities.
- Anticipate issues and needs of the customer related to the project and address them proactively.
- thereby help achieve CSS targets.
**Project / Process**:
**For Medical Management, RCM and Provider Services**:
- Ensure timely completion of tasks assigned to all team members.
- Develop SOPs and training Manuals.
- Generate periodic performance reports and dash boards for the process.
- Capture relevant metrics periodically.
- Communicate resource issues to Operation Manager.
- Inform the teams of any process updates and document the same.
- Review and update domain specifics.
**For Provider Services**:
- Communicate SLA to enabler functions based on timeframes.
- Actively participate in discussions with the Quality / PEX teams to identity process improvements.
- Lease with NSS to ensure Telecom connectivity & Proper Working of workstation as per specification.
- Lease with Admin for Transportation & all other admin related work.
- Lease with HR for on time & quality recruitment.
- Track Project Performance Quality & Quantitative Metrics.
- Ensure adherence to Quality norms and processes.
- Adhere to security practices set by organization.
- Maintain confidentiality of all information, policies, and procedures as required by the Health Insurance Portability and Accountability Act (HIPAA) protocols.
**For Medical Management and RCM**:
- Oversee daily operations, processes to ensure that all quality and efficiency standards and targets are met.
- including but is not limited to daily completion rate, accuracy of data encoded in the review, attendance and adherence to company protocols.
- Oversee the performance of new on boards and ensures coaching of the team.
- Analyze areas for improvement for meeting program objectives and participates in establishing Quality Improvement Projects for the program.
- Provide weekly coaching to the team in relation to their scope of work.
- Cascade essential information and updates to team through the weekly meetings.
- Provide regular and periodic feedback to the Program Manager on the team performance for coaching and appraisal purposes.
- Handle staff questions and escalation as necessary.
- Perform senior process executive functions as needed.
- Supervise the hiring process.
- Review all QC and QA reports and reinforce corrections and suggestions made the quality reviews team.
- Collaborate with the team and clients and assists the Operations manager with managerial activities as needed.
- Reward and discipline employees.
- address complaints and resolve problems.
- Coach and develop Nurse Reviewers, Administrative Staff, Subject Matter Experts (SME), and Team Lead to promote an understanding of the company culture, policies, goals and procedures.
**For Claims, NA, RCM and Member Services**:
- Support Knowledge transfer at the time of process transition from the business site.
- Drive team to achieve process Service Level Agreements / metrics ie productivity and quality targets within the established timelines.
- Ensure compliance controls are met.
- Ensure documented process guidelines are followed.
- conduct periodical reviews for process adherence.
- Conduct adhoc Quality checks.
- Review process audit findings and take corrective action.
- Innovate ideas to error proof the proce