---ONLY THOSE APPLICANTS WHO ALREADY HAVE THE RIGHT TO LIVE AND WORK IN THIS COUNTRY ARE ELIGIBLE TO APPLY FOR THIS ROLE--- POSITION TITLE: PHRN Claims Management Associate WORK SETUP: Hybrid RESPONSIBILITIES: • Manages incoming or outgoing telephone calls, emails, and/or faxes, including triage, opening of cases and data entry into client system. • Determines contract; verifies eligibility and benefits. • Adhere to federal and state regulatory and/or client plan requirements and established workflows • Obtains information from claimant or other supporting systems, emails and/or from fax. Manages claims, collection of non-clinical information needed for review from claimants and providers, utilizing scripts to screen basic and complex requests. • Data entry of contact into client systems and route as appropriate. • Tasks cases accurately to the correct queue. • Performs leave follow-ups as required, including recertification of health conditions, intermittent claim tracking, Return to Work confirmation, etc. • Update systems to accurately reflect leave status and ensure appropriate documentation exists. • Conducts outbound scripted calls to claimants and providers to request for clinical information. • Review and assessment of primarily complex illness and injury claims. • Identify restrictions and limitations based on physiological, psychological, and social factors to assist claim management staff in their claim handling activities. • Validate the medical necessity of limitations and/or restrictions with clear rationale. • Provide claim management staff with medical insight and education to assist them in determining appropriate determination. • Discuss medical issues and documents outcomes of discussions. • Uses available resources to understand contractual and regulatory compliance requirements and reports suspected compliance issues on the day of discovery to a Team Lead, Manager, and/or the Compliance Department. • Responsible for reporting known or suspected data disclosures or fraud on the day of discovery to a Team Lead. OTHERS: Project Shift Schedule: Night Shift Project Rest Day: Weekends Off Project/Team Location: Quezon City, Gateway Tower 2

SKILLS AND QUALIFICATIONS: • No work experience required • Holds active PHRN licensure • End-to-end claims processing or clinical work experience is good to have

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