Health Clinical Services Senior Manager, Taguig

Responsibilities:

Oversees staff whose teams 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.

Service requests may be from inbound calls and facsimile.

Outbound calls to the provider may be required to gather additional information that may be needed.

Other staff responsibilities may be review and analysis of post service claims utilizing the members benefit contract and health plan guidelines.

Completes review of pended claims post service for either Medical Necessity or Contractual Reviews.

OTHERS:

Shift Schedule: Night Shift

Rest Day: Weekends

Location: Taguig Uptown Bonifacio Tower 3

SKILL AND QUALIFICATIONS:

At least 12 years relevant experience and 10 years supervisory

Holds current and unrestricted US Registered Nurse license. No state specific RN licensure required.

BPO experience should be any account (Health account experience is only a plus, but not required)

Work Background/Experience in General: Must be open to BPO & Non-BPO Experience