Are you ready to POWER UP your skills Take the leap and join Concentrix's League of TOP-NOTCH TALENTS! Prepare for an Extra-Ordinary Journey where you not only Collaborate with Industry Champions but also immerse yourself in an Innovative Workplace filled with Laughter, Continuous Learning, and Limitless Opportunities. Join the Leading Global Provider of CX and Tech Services and seize this moment to #JoinConcentrix!
Essential Duties and Responsibilities:
- Quality Evaluation: Monitor(s), Evaluate(s) and Audit(s) a Sampling of Inbound or Outbound Call(s) and Other Contact Method(s) Including Chat(s) and Email(s), Participate in Calibration and Call Listening Session(s) with Quality Staff, Delivery, and Client(s) to Ensure Scoring Consistency and Best Practice(s) - Participate in Internal Quality Audit(s) Designed to Improve Overall Contact Quality and Recommend Change(s), Meet Audit Requirement(s) and Report Result(s) of Evaluation(s) to Stakeholder(s)
- Compliance and Documentation: Adhere to all CMS (Center(s) for Medicare and Medicaid Service(s)) Guideline(s) and Company Policies, Maintain Confidentiality of Sensitive Member Information - Accurately Document all Interaction(s) and Resolution(s) in the System, Prepare Report(s) as Required to Support Compliance and Auditing Requirement(s)
- Collaboration: Provide Insight(s) and Feedback on Recurring Issue(s) to Improve Process(es), Provide Structured Feedback to Appeals Nurse(s), Case Coordinator(s), as well as Appeals Representative(s) to Support Performance Improvement and Regulatory Compliance, Collaborate with Training and Operations to Identify Learning Gap(s) and Provide Input on Ongoing Upskilling Initiative(s), Support Audit Readiness for Client Review(s), Internal Audit(s), and Compliance Assessment(s)
Minimum Hiring Qualifications:
- Bachelor's Degree in Nursing with Active and Valid License (USRN) - 1 Year(s) Minimum Experience in Appeals and Grievances Workstream(s) with Focus on Medicare Part C Appeals - 1 Year(s) Experience in a Similar Role or Function (Quality Assurance or Quality Evaluator)
- In-Depth Knowledge and Understanding of CMS Medicare Part C Appeals Regulatory Standard(s), Strong Understanding of Clinical Terminology, Medical Necessity Review Principle(s), and Healthcare Insurance Operations, Experience Supporting External Audit(s) (CMS Program Audit(s) and Client Audit(s)) and Mentoring or Coaching New Quality Staff
- High Attention to Detail with Strong Documentation, Writing, and Scoring Calibration Skills, Proficiency in Quality Audit System(s) and Microsoft Office Suite, Strong Analytical, Critical Thinking, and Problem Solving Skills, Excellent Communication, Coaching, and Collaboration Abilities
- InterQual 1yr experience (Medicare and Medicaid)
- Willing to Work On-Site with Flexible Work Schedule(s) Including US Hour(s) and Holiday(s)
Get Hired and Enjoy the Following:
- Interact/Collaborate and Learn from Industry Experts
- Multiple Opportunities for Learning and Development
- Enjoy a Fun - and Competitive Working Environment
Work Location: Tera Tower, Bridgetowne, Quezon City
