Sagility Looking for Senior Process Executive at Bangalore Full Time

1. Determine if the request was received in writing using the Aetna Provider Complaint and Appeal form
2. Launch the appeal in the Complaint and Appeal Tracking System (CATS)
3. Ensure all available documentation is included in the file which may include inbound calls, all records related to the issues being appealed, and all letters relating to the issues being appealed that are in Electronic Correspondence Handling System (‘ECHS’)
4. Determine if the case can be resolved or must be forwarded to a subject matter expert (‘SME’)
5. Document any supporting documentation to the investigation in CATS which may include inbound calls, all records related to the issues being appealed, and all letters relating to the issues being appealed that are in ECHS and
6. Route the appeal to the appropriate SME via CATS
7. Perform final resolution once the clinical decision is returned to the analyst from the clinical teams (resolution letter, send claim to rework if required)
8. Determine if the request was received in writing using the Aetna Provider Complaint and Appeal form
9. Determine the appellate (who has submitted the appeal)
10. Confirm through available systems (e.g., CATS, ECHS, Aetna Strategic Desktop (‘ASD’),etc.) if the request is a new appeal, a duplicate appeal, an exhausting appeal, or if the issue is too late to appeal
11. Launch the case in CATS

Requirements:

1. Minimum 1+ years of claims adjudication experience (both medical & hospital claims),rework experience is preferred
2. Those with past claims adjudication experience and currently working with non-claims business areas (for example overpayment, correspondence, CG&A, MCM, etc.) are also eligible to apply
3. Preferred working knowledge of provider/provider correspondence or engagement platforms
4. Good written communication skills to respond to providers conveying a positive and professional image (of our client) are essential
5. Ideal candidates should possess the probing skills necessary to request additional information that may be required to resolve provider issues
6. Able to self-direct and monitor their case management (sending letters, follow-ups, and resolving the case with appropriate actions/notes)
7. Ability to meet and exceed quality, production, and TAT goals as per set expectations