Job Description

JOB DESCRIPTION Role Proficiency: A Voice Associate Able to independently take customer support calls effectively and efficiently follow the SOPs to complete the process and endeavour to resolve the issue handle some escalated issues or escalate to a more knowledgeable person to resolve in alignment with SLAs and assists Lead I - BPM.rnA Data Associate should independently be able to effectively and efficiently process the transactions assigned in timely manner clarify complex transactions to others and ensure that quality of output and accuracy of information is maintained in alignment with SLAs and assists Lead I - BPM. Outcomes: Independently achieves the following guiding other process associates and assists Lead 1 - BPM Service Level Agreement (SLAs) specified by the client in terms of quality productivity and schedule should be managed to ensure 100% adherence. Data: Analyze information enter and verify data follow the SOP to ensure completion of the task. Voice: Customer calls responses and any updates or edits to workflow based on after call work should be performed as per directions. Address performance issues and improvement plans of team and self with supervisor. Expected to be proficient in the process and domain to ensure quality of transactions and guide the same to the process associates. Perform QA for production associates as an expert in the function and ensure completion within SLAs. Create reports on performance metrics for team to manage productivity. Understand the process and bring forward ideas and solutions to simplify and automate them to increase operational efficiency. Create automation solution and submit the same to Lead I for review. Measures of Outcomes: 100% Adherence to quality standards Adherence to turnaround time for response and resolution Completion of all mandatory training requirements 100% adherence to process and standards 100% adherence to SLAs where applicable Number of issues fixed/tasks completed Number of non-compliance issues with respect to SOP Zero/No Client Escalations Number of high-quality RCA and QA output Daily/weekly performance reporting Mentors A1 and A2 resources on the processes Outputs Expected: Processing Data: Processing transactions assigned as per SOPs Handling calls Voice: Handle customer support calls resolve issues and complete after-call work Production: Take calls (voice) or process complex transactions (data) Issue Resolution: Address any problems with the supervisor/QA to ensure maximum productivity and efficiency. Identifies analyses and solves the incidents/transactions. Productivity: Proficient in the process assisting other team members who are new to the process as well to ensure quick readiness of the team. Take steps to improve performance based on coaching. Production readiness of new joiners within agreed timeline by providing guidance Actively participate in the team\'s or organization wide initiatives Able to handle and manage higher complexity tasks. Adherence: Be aware of any clients process or product updates and ensure 100% compliance towards the same. Adhere to release management process. Thorough understanding of organization and customer defined process. Consult with mentor when in doubt. Adherence to defined processes. Adhere to organization\' s policies and business conduct. Reporting: Create reports on specific SLAs/performance measures/KPIs Stakeholder Management: Guide the team in preparing status updates and keep management updated about the status. Training : Attends one on one need-based domain/project/technical trainings as needed. On time completion of all mandatory training requirements of organization and customer. Provide on floor training and one to one mentorship for new joiners. Escalation: Escalate problems to appropriate individuals/support team based on established guidelines and procedures. Monitoring: Monitor progress of requests for support and ensures users and other interested parties are kept informed. Manage knowledge: Consume project related documents share point libraries and client universities Mentoring: Mentor and provide guidance to peers and junior associates. Assist new team members in understanding the customer environment. Communication: Status update to the respective stakeholders and within the team Collaboration: Collaborate with different towers of delivery for quick resolution (within SLA) document learning\'s for self-reference. Collaborate with other team members for timely resolution of errors. Skill Examples: Customer Focus: Focus on providing a prompt and efficient service to customers goes out of the way to ensure that individual customer needs are met. Attention to detail to ensure SOPs are followed and mistakes are not knowingly made Team Work: Respect others and work well within the team. Communication: Speak clearly and write in a clear and concise manner. Uses appropriate style and language for communication (Data) Communication: Speaks in an accent neutral manner or with the accent required for the process with good vocabulary and grammar skills. Writes clearly (Voice) Typing Speed with 15WPM and 80% accuracy Analytical approach: Makes systematic judgments based on information and relevant assumptions. Ability to follow SOP documents and escalate the alerts within the defined SLA Willingness and ability to learn new skills domain knowledge etc. Make rule based and discretionary decisions. Process Trainer/Sr. QA/Domain Expert/MIS Analyst Frontline resource - Voice/Backoffice Quality Auditors SME Domain Experts Knowledge Examples: Expertise with Windows Operating Systems MS Office tools English comprehension - Reading writing and speaking Domain knowledge based on process (healthcare banking investment F&A retail customer support etc) Familiarity with work allocation and intake functions Familiarity with quality control processes including pare to analysis and root cause analysis Knowledge on security policies and tools Good understanding of customer infrastructure ability to co-relate failures Experience level - 3 to 7 years Additional Comments: Appeals and Grievances Analyst Who we are: At UST HealthProof, you will join a fast paced, growing company in our mission to reshape the future of health insurance through significantly reducing administrative costs and building better healthcare experiences for our health plans customers and their members. By creating a modern, cloud based, Best-In-Class core administration ecosystem, we have made healthcare more affordable and helped our health plans operate more efficiently. Through member and provider touchpoints with less friction, we have created real impact for member. UST HealthProof is run by leaders with strong health plan and technology background with a start up mindset and an environment of support where individual growth is nurtured. You will be supporting our proven core admin solutions and business process-as-a-service (BPaaS) operations to provide transparency, improve operational efficiency, break down operational barriers to scale and drive strategic growth. Job Summary: UST HealthProof is searching for Appeals and Grievances Analysts, acting in a quality assurance capacity, is responsible for the processing Appeals and Grievances by evaluating the organization\'s initial decisions against CMS guidelines and enrollee benefits, by preparing a detailed summary statement of the appeal or grievance case, including research to substantiate the appeal or grievance, and for the end-to-end processing of each case. All Appeals and Grievance cases must be documented in the highest quality possible, ensuring the Appeals and Grievances are performed timely, accurately and in accordance with CMS Grievance and Appeals regulations. As an A&G Analyst at UST HealthProof, this is your opportunity to: . Follow Grievances and Appeals processes and systems to ensure data quality to support UST HealthProof\'s quality, production and financial goals. . Investigate and thoroughly document findings on all grievances and appeals. . Prepare Appeal case recommendations for initial review process. . Coordinate appropriate reviewer assignment for Appeals and Grievance cases. . Responsible to move Appeals and Grievances through each review level to ensure timely completion. . Drive operational excellence into all processes and departmental interactions based on CMS and UST HealthProof\'s requirements. . Bring to management\'s attention any system or process issues determined during the investigation of the appeal or grievance. . Coordinate effectively with the Information technology department on upgrades/fixes/changes. . Participate in the departmental audit/oversight program that focuses on continuous quality improvement. . Participate in compliance committees to help continuously improve initial decision making. . This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required. . You bring: . Bachelor\'s degree in business administration, Economics, Health Care, Information Systems, Statistics or other related field is required. Master\'s Degree in related field preferred. Relevant combination of education and experience may be considered in lieu of degree. Certification or progress toward certification is highly preferred and encouraged. . Experience in a grievance and appeals environment including experience with the grievance and appeals regulations per CMS. . Experience in medical benefits and health care industry regulations and processes experience in claims, authorizations, and Medicare Advantage plans. . Experience working in or with Medicare Advantage plans, or Independent Review Entities. . Experience with CMS regulations regarding Medicare Advantage, and Medicare Advantage plans appeals and grievance processes. . Knowledge in claims, authorizations, and Medicare Advantage plans. . Proven problem-solving skills and ability to translate knowledge to corporate departments. . Strong communication skills are required to understand, interpret, and communicate ideas. . Strong knowledge and use of existing software packages (PowerPoint, Excel, Word, etc). . Strong analytical, organizational, planning and problem-solving skills. . Ability to effectively interface with employees at all levels. . Ability to define problems, collect data, establish facts, and draw valid conclusions. . Demonstrated track record of generating results and having an impact on organizations. . Strong focus and drive to serve the customer. . Ability to work in a high paced environment. . Ability to consistently exceed deadlines.

foundit