DE030193-PHRN Claims Management Associate
1 week ago
DE -PHRN Claims Management Associate Join to apply for the DE -PHRN Claims Management Associate role at myGwork - LGBTQ+ Business Community This job is with Accenture, an inclusive employer and a member of myGwork – the largest global platform for the LGBTQ+ business community. Please do not contact the recruiter directly. Responsibilities Manages incoming or outgoing telephone calls, emails, and/or faxes, including triage, opening of cases and data entry into client system. Determines contract; verifies eligibility and benefits. Adheres to federal and state regulatory and/or client plan requirements and established workflows. Obtains information from claimant or other supporting systems, emails, and/or fax; manages claims, collection of non-clinical information needed for review from claimants and providers, utilizing scripts to screen basic and complex requests. Data entry of contact into client systems and route as appropriate. Tasks cases accurately to the correct queue. Performs leave follow‑ups as required, including recertification of health conditions, intermittent claim tracking, Return to Work confirmation, etc. Updates systems to accurately reflect leave status and ensure appropriate documentation exists. Conducts outbound scripted calls to claimants and providers to request clinical information. Reviews and assesses primarily complex illness and injury claims. Identifies restrictions and limitations based on physiological, psychological, and social factors to assist claim management staff in their claim handling activities. Validates the medical necessity of limitations and/or restrictions with clear rationale. Provides claim management staff with medical insight and education to assist them in determining appropriate determination. Discusses medical issues and documents outcomes of discussions. Uses available resources to understand contractual and regulatory compliance requirements and reports suspected compliance issues on the day of discovery to a Team Lead, Manager, and/or the Compliance Department. Is responsible for reporting known or suspected data disclosures or fraud on the day of discovery to a Team Lead. Qualifications No work experience required. Holds active PHRN licensure. End‑to‑end claims processing or clinical work experience is good to have. Shift Information Project Shift Schedule: Night Shift Project Rest Day: Weekends Off Project/Team Location: Quezon City, Gateway Tower 2 Location: Quezon City, National Capital Region, Philippines #J-18808-Ljbffr
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Cebu City, Philippines HRTX Full timeQualifications : PHRN with active license Minimum 1 year BPO Healthcare experience Minimum 1 year Hospital Bedside Experience Willing to work onsite in IT Park, Cebu Willing to work on night shift schedule
