DE033514-Health Clinical Services Analyst

---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 Services Analyst WORK SETUP: Return to Office RESPONSIBILITIES: • Determines contract; verifies eligibility and benefits. • Conducts a thorough provider radius search in client system and follows up with provider on referrals given. • Checks benefits for facility-based treatment. • Obtains intake (demographic) information from callers, e-Reviews, and/or from faxes. Processes incoming requests, collection of non-clinical information needed for review from providers, utilizing scripts to screen basic and complex requests for pre-certification and/or prior authorization. • Performs data entry of contact into client systems and routes as appropriate. • Matches fax/clinical records with appropriate case. • Consolidates inputs for approval. • Generates the needed letters as directed by the client and/or outlined in the client’s procedure manual. • Assigns cases/activities and work within the client’s system to facilitate workflow and productivity goals. • Refers cases requiring clinical review to a nurse reviewer. Performs case checks and reviews to ensure case creation is complete and correct for the clinician • Tasks cases accurately to the correct queue. • Conducts outbound scripted calls to providers to request clinical information as directed by the clinician. • Conducts outbound scripted calls to providers to complete approval notification process as directed by the clinician. • Performs Daily Task list maintenance activities under the direction of the Team Lead/Operations Manager and as per customer workflow. • Provides administrative support to Nurse Reviewer via case preparation, phone number verification, medical record requests and verbal call out approval notifications. • Provides administrative support of post service claims utilizing the member’s benefit contract and health plan guidelines. • Performs administrative tasks and work as directed by clinician or Team Lead/Operations.? Consults clinician and Team Lead/Operations Manager timely and appropriately. • Reports inventory numbers and assigns task lists under the direction of the Team Lead/Operations and as requested by the customer. • Prioritizes follow-up and actions based on case request receipt dates, customer workflow, service level agreements and regulatory timeframes. • Responsibilities exclude collection of non-scripted information, evaluation, or interpretation of clinical information, and providing medical advice/opinion on treatment or services. OTHERS: Project Shift Schedule: Night Shift Project Rest Day: Weekends Off Project/Team Location: Quezon City, Gateway Tower 2SKILLS AND QUALIFICATIONS: • Holds a current and unrestricted Philippines Registered Nurse license. • At least 3 months of clinical experience, which can include internships or volunteer work, not necessarily only in hospitals. • Work experience should be as a registered nurse and not from before obtaining the license or taking the board exam. Good to have only: • Prior experience in healthcare setting/environment such as Utilization Management, Intake Representative, Health Insurance Claims Processor or Health Outreach Specialist is highly preferred.

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