​​US Healthcare Specialist - Immediate joiners

US Healthcare Specialist -Immediate joiners

Location

Mohan Cooperative, New Delhi

Opening

5

Required Experience

3 - 6 years

Role

Customer Success, Service & Operations - Other

Industry Type

Analytics / KPO / Research

Department

Customer Success, Service & Operations

Employment Type

Full Time, Permanent

Role Category

Customer Success, Service & Operations - Other

Education

UG

Any Graduate

PG

Any Postgraduate

Key Skills

Authorization

Enrollment

Insurance Verification

US Healthcare

Excel

Eligibility Verification

Revenue Cycle Management

AR Calling

Back Office Operations

Data Entry

Medical Billing

Data Entry Operation

Perks and Benefits

Best in industry

Job description

The Specialist ensures that healthcare services are delivered efficiently and meet quality standards while aligning with the organizations policies and regulatory requirements. The role involves reviewing medical records, coordinating care, and working with healthcare providers to manage patient treatment plans in a cost-effective manner.

Key Responsibilities

Utilization Review

Evaluate the medical necessity, appropriateness, and efficiency of healthcare services.

Conduct pre-certification, concurrent, and retrospective reviews of care.

Ensure compliance with applicable guidelines and regulations.

Case Management Coordination

Collaborate with healthcare providers, payers, and patients to coordinate care and services.

Advocate for optimal patient outcomes while managing resource utilization.

Documentation and Reporting

Maintain accurate and up-to-date records of reviews, authorizations, and patient information.

Prepare reports on utilization trends, compliance issues, and quality metrics.

Policy Compliance

Ensure adherence to organizational policies and external regulatory standards.

Stay updated on industry standards and best practices in utilization management.

Patient and Provider Communication

Educate patients and providers about treatment options, insurance requirements, and care pathways.

Resolve disputes related to denied claims or coverage issues.

Required Qualifications

Education

Bachelors degree in any field

Experience

Minimum 3-6 years in healthcare or case management

Experience with insurance providers, hospital administration, or managed care organizations is desirable

Skills and Competencies

Strong understanding of medical terminology, clinical practices, and healthcare regulations (e.g., CMS, HIPAA)

Proficiency in electronic medical records (EMRs) and utilization management software

Excellent communication, problem-solving, and decision-making abilities

Ability to analyze and interpret clinical data effectively

Knowledge of payer systems, billing processes, and managed care principles

Work Environment

May involve working closely with an insurance company / managed care setting

Work from office / US hours

Immediate joiners required

Candidates should be open to working in night shift

No cab