Process Associate

Academic Qualification and external certification required Bachelor’s Degree preferred; High School / GED with relevant experience may be considered Range of experience in months 1 -3Years The Responsibilities which will be played by the role • Adjudicate member and provider claims accurately in line with plan benefits, regulatory requirements, client policies and SOPs • Validate member eligibility, benefit coverage, provider status, authorisation, coding, pricing and accumulator impact before finalising claims • Process professional and facility claims, including corrections, adjustments, rework and denied or pended claims • Research and resolve claim edits and exceptions using Plexis, EZ-CAP, Facets or the applicable client platform • Document claim decisions and supporting rationale clearly in the client system • Escalate configuration, benefit, provider-data or system issues with complete evidence • Consistently meet productivity, quality, compliance and turnaround-time requirements • Support peer queries and share process knowledge as an experienced resource

Do

Support process by managing transactions as per required quality standards

Fielding all incoming help requests from clients via telephone and/or emails in a courteous manner

Document all pertinent end user identification information, including name, department, contact information and nature of problem or issue

Update own availability in the RAVE system to ensure productivity of the process

Record, track, and document all queries received, problem-solving steps taken and total successful and unsuccessful resolutions

Follow standard processes and procedures to resolve all client queries

Resolve client queries as per the SLA s defined in the contract

Access and maintain internal knowledge bases, resources and frequently asked questions to aid in and provide effective problem resolution to clients

Identify and learn appropriate product details to facilitate better client interaction and troubleshooting

Document and analyze call logs to spot most occurring trends to prevent future problems

Maintain and update self-help documents for customers to speed up resolution time

Identify red flags and escalate serious client issues to Team leader in cases of untimely resolution

Ensure all product information and disclosures are given to clients before and after the call/email requests

Avoids legal challenges by complying with service agreements

Deliver excellent customer service through effective diagnosis and troubleshooting of client queries

Provide product support and resolution to clients by performing a question diagnosis while guiding users through step-by-step solutions

Assist clients with navigating around product menus and facilitate better understanding of product features

Troubleshoot all client queries in a user-friendly, courteous and professional manner

Maintain logs and records of all customer queries as per the standard procedures and guidelines

Accurately process and record all incoming call and email using the designated tracking software

Offer alternative solutions to clients (where appropriate) with the objective of retaining customers and clients business

Organize ideas and effectively communicate oral messages appropriate to listeners and situations

Follow up and make scheduled call backs to customers to record feedback and ensure compliance to contract /SLAs

Build capability to ensure operational excellence and maintain superior customer service levels of the existing account/client

Undertake product trainings to stay current with product features, changes and updates

Enroll in product specific and any other trainings per client requirements/recommendations

Partner with team leaders to brainstorm and identify training themes and learning issues to better serve the client

Update job knowledge by participating in self learning opportunities and maintaining personal networks

Deliver

No Performance Parameter Measure 1 Process No. of cases resolved per day, compliance to process and quality standards, meeting process level SLAs, Pulse score, Customer feedback 2 Self- Management Productivity, efficiency, absenteeism, Training Hours, No of technical training completed

Mandatory Skills: Claims_Processing.

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