DE033452-Health Operations Associate

Accenture PLC; Quezon City; On-site; PHP 335,000 - 536,000; Full time

Job summary

Accenture PLC in Quezon City is seeking a Health Operations Associate for a night-shift, return-to-office setup. You will handle eligibility checks, provider referrals, and benefits verification, while gathering intake data and processing pre-certifications and prior authorizations.

The role involves data entry, document matching, letter generation, and case routing to support clinicians and nurse reviewers. Strong English communication and 6 months of BPO experience are preferred.

Qualifications

• 6 months BPO work experience or more
• Excellent written and verbal English communication
• Pass US CEFR B2 level or Versant score requirement for voice accounts
• Proficiency with basic computer programs
• Knowledge of utilization management and member contracts Benefitso
• Experience in United States medical/insurance field and CPT/ICD knowledge

Responsibilities

• Verify eligibility and benefits and determine contract.
• Conduct provider radius searches and follow up on referrals.
• Check benefits for facility-based treatment.
• Obtain intake information and process requests for pre-certification and/or prior authorization.
• Perform data entry and route cases in client systems.
• Match fax/clinical records to cases and consolidate inputs for approval.
• Generate letters and assign cases to appropriate queues.
• Refer cases for clinical review to a nurse reviewer as needed.
• Outbound calls to providers to obtain information and notify approvals.
• Support daily task lists and provide administrative support to clinicians.

Skills

English communication

Customer service

Empathy

Active listening

Phone etiquette

Prioritization

Caseload management

Education

College degree or high school diploma

Tools

Client systems

Job description

---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 Operations Associate

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 at a time and appropriately.

Others

• Project Shift Schedule: Night Shift
• Project Rest Day: Weekends Off
• Project/Team Location: Quezon Gateway Tower 2

Skill and Qualifications

• Graduate of any college degree or High School Diploma with 6 months’ BPO work experience
• At minimum 6 months of work experience.
• Excellent written and verbal communication skills in English
• For voice accounts, must pass US CEFR B2 level or Versant score of 58 or any language proficiency equivalence.
• Proficiency in basic computer knowledge with the ability to learn additional computer programs.
• Experience and Skills Preferred
• Knowledge of utilization management process and ability to interpret and apply member contracts, and member benefits.
• Prior clinical BPO experience
• Strong customer service focus
• Ability to empathize.
• Prioritizing customer needs
• Listening, patience & action oriented
• Good understanding of phone etiquette
• Claim reviews/audit experience.
• Experience in United States medical or insurance field
• Knowledge of ICD-9 and ICD-10 and CPT codes
• Experience in medical or insurance field

Working Conditions

• Cyclical work shift including work hours at night; able and willing to work U.S. time and as needed.
• Overtime and On-Call may be required to meet the needs of the client/business.
• Employees are able to travel to and work/train in the office as required and requested by management.
• Additional tasks may be assigned by your Immediate Supervisor/Project Manager.
• Holidays are observed in compliance with client-specific contracts or statements of work (SOW).
• For Remote/Work from Home Employees: Ability to work independently

Equal Employment Opportunity Statement

All employment decisions shall be made without regard to age, race, creed, color, religion, sex, national origin, ancestry, disability status, veteran status, sexual orientation, gender identity or expression, genetic information, marital status, citizenship status or any other basis as protected by federal, state, or local law.

Job candidates will not be obligated to disclose sealed or expunged records of conviction or arrest as part of the hiring process.

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