Cigna Helium - Case Reviewer
Job Code : REQ-005968
Quezon City Fully RemoteJob Description
Sagility combines industry-leading technology and transformation-driven BPM services with decades of healthcare domain expertise to help clients draw closer to their members. The company optimizes the entire member/patient experience through service offerings for clinical, case management, member engagement, provider solutions, payment integrity, claims cost containment, and analytics. Sagility has more than 25,000 employees across 5 countries.
Job title:
Job Description:
A Senior Customer Service Representative (Sr.CSR) Clinical handle concerns from respective client either through voice support or non-voice assistance. Transactions are of specialized nature as it pertains to specific and detailed medical details
? Accesses the appropriate coverage criteria.
? Performs Utilization Management review in accordance to federal and state mandated regulations, HUM URAC standards and client requirement and/or policies.
? Maintains compliance with regulatory changes affecting Utilization Management.
? Reviews the clinical information and treatment requests against established clinical review criteria, and determine if the criteria is met or not.
? Documents the review.
? Protects and secures member?s Protected Health Information (PHI).
? Responds to inbound calls pertaining to reviews in a timely manner, following client-established protocols.
? Participates in discussion rounds with the Medical Director.
? Arrives at a medical necessity decision conducting one of the following 3 things as an end result:
o Nurse approves requests that meet the criteria
o Nurse contractually denies requests excluded in member contract
o Nurse routes requests not meeting criteria to RMD or refers for Peer-to-peer
? Notifies provider and member of decision through outbound calls.
Performance Management:
- Responsible for monitoring in an objective fashion all cases processed by nurses.
- Responsible for reporting all behavior that does not conform to the quality standards set by the company and the account management.
- Provides quantifiable data to all quality judgements that are made.
- Conducts calibration session with the client and with Operations.
- Coordinates with respective Onshore Sustainment Coach/es to ensure an acceptable level of repeatability and reproducibility of audited transactions.
- Works with operations as an auditor as well as regulator of quality issues.
- Works with Training and Operations to provide trend reports to address any issues that need refresher training.
- Follows other tasks and/ or offline tasks assigned by his direct Supervisor/Manager.
General Safety and Security
- Protects the organization?s assets by upholding the principles of the Quality Information Security Management System (QISMS).
- Ensures confidentiality, integrity, and availability of information critical to fulfilling the organization?s business functions.
- Remain compliant with the relevant business, local and international regulatory and legislative requirements particularly the Health Insurance Portability and Accountability Act of 1996 (HIPAA), HITECH Act and URAC
With Basic Competency Level in the ff.:
Excellent interpersonal skills Ability to understand and interpret policy provisions. Product knowledge Typing Skills Problem Solving Skills
With Moderate Competency Level in the ff.:
US Healthcare Delivery System Philippine Healthcare Delivery System Clinical Skills US Healthcare 101 Customer Service orientation Computer literate Interpersonal Skills Sense of Urgency Passion for Excellence
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