Responsibilities:

Oversees staff whose teams’ 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. 

• Service requests may be from inbound calls and facsimile.

• Outbound calls to the provider may be required to gather additional information that may be needed.

• Other staff responsibilities may include review and analysis of post-service claims utilizing the member’s benefit contract and health plan guidelines.

• Completes review of pended claims post-service for either Medical Necessity or Contractual Reviews.

SKILL AND QUALIFICATIONS:            

• At least 12 years of relevant experience and 10 years of supervisory experience

• Holds current and unrestricted US Registered Nurse license. No state-specific RN licensure required.

• BPO experience should be any account (Health account experience is only a plus, but not required)

• Work Background/Experience in General: Must be open to BPO & Non-BPO Experience

• Open for those applicants who are currently in Philippines and already have the right to live and work in this country  are eligible for this role