We’re looking for candidates with the following skills and experience for this role. Do you fit the profile? If you do, we’d love to hear from you! In adherence to Accenture’s process of Identity Verification, your resume or CV must include your photo to ensure the accuracy of your application.

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

• Should not be a job hopper who only works for less than a year per company