DE033108-Health Clinical Svcs Specialist

---ONLY THOSE APPLICANTS WHO ALREADY HAVE THE RIGHT TO LIVE AND WORK IN THIS COUNTRY ARE ELIGIBLE TO APPLY FOR THIS ROLE--- POSITION TITLE: Health Clinical Svcs Specialist WORK SETUP: Hybrid RESPONSIBILITIES: Oversees staff whose 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 (UM service requests are received from inbound calls and facsimile. Outbound calls to the provider may be required to gather additional information that may be needed) • Responsible for maintaining contractual, regulatory and accreditation compliance by knowing, understanding, correctly interpreting, and accurately applying requirements, regulations and standards. Reports suspected or confirmed issues on the same day of discovery to the manager and/or the Compliance Department. • Responsible for ensuring Associate understanding of contractual, regulatory and accreditation requirements and reporting immediately all suspected or confirmed issues or concerns to a manager and/or the Compliance Department. • Responsible for ensuring that all clinical USRN associates maintain active, documented licensure while working in production. Removes clinical associates from production when active USRN licensure is not verified by the PMO team. Reports instances of expired or lapsed licensure on the date of discovery to the PMO team and to the Compliance Department. • Facilitates accreditation by participating in and/or conducting audits as needed. • Provides leadership, mentoring, and supervision of staff. • Responsible for reporting known or suspected data breaches on the day of discovery to the Compliance Department and for conducting a follow-up investigation as needed. • Performs Root Cause Analysis (RCA) for performance deviations and implement improvement plans and associate coaching as needed. • Studies and analyzes VOC (Voice of customer) trends and customer feedback and work towards improving performance. • Performance Management • Performs regular performance management steps in managing team performance. • Responsible for ongoing staff performance tracking; daily, weekly and month to date. • Schedules 1x1 coaching sessions as needed, discusses with the associate goals and objectives required, documents all discussions, and sets time frame to meet goals and provides timely follow-up with the associate. • Derives data from client system and looks at current inventory levels to establish action items. • Reviews quality data (client audits and desk level audits) and analyzes root causes with team for action planning. • Oversees goal setting or all associates at the start of the fiscal year in compliance with the annual review process. • Identify and enroll associate’s in performance Improvement Plans (PIPs) as needed and have supporting data available (performance, qualitative as well as coaching documentation). • Meets or exceeds all performance metrics. Responsible for associates’ production and quality targets. OTHERS: Project Shift Schedule: Night Shift Project Rest Day: Weekends Off Project/Team Location: Taguig Uptown Bonifacio Tower 3

SKILL AND QUALIFICATIONS: • Holds active, unrestricted US Registered Nurse license. • Bachelor of Science in Nursing (BSN) degree • A minimum of three (3) months of prior working experience as a Registered Nurse in a clinical setting required post graduate- working experience in a clinical setting (inpatient or outpatient direct patient care) required • Three months is equivalent to 480 hours of working experience as an RN • Working experience as a Registered Nurse means holding an active RN license and providing direct patient care • Clinical setting includes inpatient hospital, outpatient hospital, or clinic • With at least 3 months’ experience in Utilization Review or Medical Appeals and Grievance (aligned to the profiles benchmarked during live sourcing.) Good to have only: • At least 1 year experience as a Supervisor/Team Lead (in any industry) Flexes: • Open to CL8 role based on Recruitment and Project assessment

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