**Not Applicable****Qualification**:**Graduate (exclusion**:BE/BTech/MCA)- For Medical Management Bachelor's degree in Nursing or any health science related field.- For NA High School Equiv.**Responsibility**:**Business / Customer**:**Data Processes**:- Efficiently Process predefined number of transactions as assigned with highest level of accuracy as agreed upon by the client.- Provide highest level of customer satisfaction.- Strive to understand and resolve issues/queries at the first instant.- Maintain the business controls as per the requirement.- Articulate/ communicate in a manner which is understood by clients / endusers.- Connect & provide highest level of satisfaction to the customer.**For Member Management**:- Generate clientspecified reports relating to operations.- Respond to data requests and other inquiries from the client.- Release WCUM determinations to claim stakeholders following clientestablished protocols.- Identify the medical flags in the client system.- Provide reports and other data requests specified by the client.- Serve as first level contact for customer complaint resolution.- Provide reports and other data requests specified by the client.**For NA**:- Take ownership of delivery including any customer communication and handle queries / clarifications from the customer.**Voice Processes**:**For Claims, RCM, Provider Services and Member Services**:- Make and Answer calls to and from customers/end users based on agreed time frames.- Transfer calls involving next level of service to the appropriate department as per the given guidelines.**Project / Process**:**Data Processes**:- Ensure to meet all Statistical, Financial and TAT metrics while processing claims.- 100% Process adherence to transaction processing timelines involving medical management processes.- Adhere to audit compliance (Internal, Statutory Audit) of all Healthcare processes as laid out by Cognizant / the client of Cognizant.- Ensure process guidelines are followed and met as documented.- Set productivity /Quality benchmark.- Adhere to shift handover processes.- Raise process related issues / concerns on time with process and team leads.- Record data relating to production statistics, enduser related notes, etc as appropriate.- Stay updated with the process knowledge / changes refer to knowledge updates/ repositories to effectively process transactions.- Adhere to security practices set by organization.- Implement small process improvement projects.- Provide updates and submit reports related to own area of work.- Resolve process related queries and expedite on data requests.- Respond to data requests.- Maintain confidentiality of all information, policies, and procedures as required by the Health Insurance Portability and Accountability Act (HIPAA) protocols.- Maintain acceptable levels of performance including but not limited to attendance, adherence to protocols, customer courtesy, and all other productivity and efficiency targets and objectives.- Contribute new ideas and innovative approaches at work.- Participate in project and organization initiatives led by the Delivery leadership.**For Medical Management**:- Identify cases eligible for medical reviews and assign these to appropriate reviewers.- Reach out to the client for any problems identified in the cases for review.- Adhere to Utilization Review Accreditation Commission (URAC), jurisdictional, and/or established MediCall best practice UM time frames, as appropriate.- Adhere to federal, state, URAC, client, and established MediCall best practice WCUM time frames, as appropriate.- Develop a complete understanding of the Medical management Procedures.- Perform medical review assessment (MRA) on utilization of health services (eg healthcare plans, workers compensation products etc) in an accurate, efficient and timely manner while ensuring compliance with utilization management regulations and adherence to state and federal mandates.- Provide succinct negotiable points based on the submitted medical records that identify necessary medical treatment, casually related care, response or lack of response to treatment, etc.- Identify missing records and information that are necessary in the completion of the medical review assessment.- Adhere to Department of Labor, state and company timeframe requirements.- Coordinates physician reviewer referral as needed and follows up timely to obtain and deliver those results.- Track status of all utilization management reviews in progress and follow up on all pending cases.- Work closely with management team in the ongoing development and implementation of utilization management programs.- Respond to inbound telephone calls pertaining to medical reviews in a timely manner, following clientestablished protocols.- Process customer calls consistent with program specified strategies and customer satisfaction measurements to include but not limited to pr
