Analyze and launch appeals and conduct outreach calls to US based health insurance members to validate information/data discrepancies.
• Performs outreach calls to US based provider offices with pre-identified discrepancies in the service location(s) and name, in order to comply with a US Directory Accuracy mandate.
• Pull samples from client's online provider directories to identify erroneous information that may adversely impact network adequacy monitoring and reporting. Perform outreach calls as necessary.
• Quarterly audit of provider directory in specific states to identify erroneous data that may adversely impact network adequacy monitoring and reporting using NCQA audit method. Data elements subject in this audit are the provider's name, service location, service location phone number, accepting new patients indicator, specialty/provider type, non-English language and hospital affiliation.
• Retain skills in functional area of expertise through frequent "on the role" experiences and ongoing education, training and certification.
SKILLS AND QUALIFICATIONS Qualifications: • College graduate • Ability to communicate clearly and fluently using the English language • Claims processing background preferred but not required Working Conditions: • Moderate to no travel depending on project involvement • Cyclical work shift including work hours at night • Overtime and On-Call may be required • Client holidays are observed instead of Philippine or local holidays
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