Job Description

Skill required:

Claims Appeals - Claims Administration

Designation:

Health Admin Services New Associate

Qualifications:

Any Graduation

Years of Experience:

0 to 1 years

About Accenture

Accenture is a global professional services company with leading capabilities in digital, cloud and security.Combining unmatched experience and specialized skills across more than 40 industries, we offer Strategy and Consulting, Technology and Operations services, and Accenture Song-- all powered by the world's largest network of Advanced Technology and Intelligent Operations centers. Our 699,000 people deliver on the promise of technology and human ingenuity every day, serving clients in more than 120 countries. We embrace the power of change to create value and shared success for our clients, people, shareholders, partners and communities.Visit us at www.accenture.com

What would you do?

To provide support to the clinical team and client team to assist in the promotion of quality member outcomes, to optimize member benefits, and to promote effective use of resources. Supports the procedures that ensure adherence to medical policy and member benefits in providing service that is medically appropriate, high quality, and cost effective. Utilization Management: Gathers information using the appropriate client-specific telephonic screening tools. Conducts pre-review screening under the guidance and direction of US licensed health professionals. Case Management/Disease Management -Provides support functions for wellness programs, health management programs and preventative care opportunities that the member may have as part of their benefits. Gathers information using the appropriate client-specific telephonic screening tools.

What are we looking for?

oMicrosoft Excel oMicrosoft PowerPoint oWritten and verbal communication oRelated outsourcing operations experience oClaims reviews/audit experience and data entry experience oKnowledge of utilization management process and ability to interpret and apply member contracts, and member benefits oKnowledge of ICD-9 and ICD-IO and CPT codes, preferred oExperience in medical or insurance field, preferred oRequires solving of routine problems, largely through precedent and referral to general guidelines. oInteraction is within own team and direct supervisor oRequires analysis and solving of increasingly complex problems. oInteraction is with peers within Accenture before updating supervisors. Likely has some interaction with clients and/or Accenture management. With proper guidance and oversight by Team Lead, may be tapped for precepting, training, mentoring and job shadowing duties oHolds current and unrestricted local (PH) Registered Nurse license. oBachelor of Science Nursing (BSN) degree oExcellent written and verbal communication skills in English oMust pass American English and alternate language fluency test ("Test") upon hire (non-US resident) by successfully completing internal written test. For voice accounts, you must pass US Berlitz B2 level or Versant score 58 and above upon hire or upon assuming role. oProficiency in basic computer knowledge with the ability to learn additional computer programs oA minimum of three (3) months of prior working experience as a Registered Nurse in a clinical setting required o Three months is equivalent to 480 hours of working experience as an RN o Work experience as a Registered Nurse means holding an active RN license and providing direct patient care o Clinical setting includes inpatient hospital, outpatient hospital or clinic, or 1-year related Accenture or other outsourcing experience or returning Analyst employee oStrong customer service focus o Ability to empathize o Prioritizing customer needs

Roles and Responsibilities:

oManages incoming or outgoing telephone calls, e-Reviews, and/or faxes, including triage, opening of cases and data entry into client system. oDetermines contract; verifies eligibility and benefits. oConducts a thorough provider radius search in client system and follows up with provider on referrals given. oChecks benefits for facility-based treatment. oObtains intake (demographic) information from caller, e-Reviews, and/or from fax. 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. oPerforms data entry of contact into client systems and routes as appropriate Match fax/clinical records with appropriate case. oConsolidate inputs for approval. oGenerate the needed letters as directed by client and/or outlined in client s procedure manual oAssign cases/activities and work within client s system to facilitate workflow and productivity goals. oRefers cases requiring clinical review to a nurse reviewer. Performs case checks and reviews to ensure case creation is complete, correct, and "nurse ready". oTasks cases accurately to the correct queue. oConducts outbound scripted calls to providers to request clinical information as directed by clinician. oConducts outbound scripted calls to providers to complete approval notification process as directed by clinician. oPerforms Daily Task list maintenance activities under the direction of the Team Lead/Operations Manager and as per customer workflow. oProvide administrative support to /Nurse Reviewer via case preparation, phone number verification, medical record requests and verbal call out approval notifications. oProvide administrative support of post service claims utilizing the member s benefit contract and health plan guidelines. oPerforms administrative tasks and work as directed by clinician or Team Lead/Operations. Consults clinician and Team Lead/Operations Manager timely and appropriately. oReports inventory numbers and assigns task lists under the direction of the Team Lead/Operations and as requested by the customer. oPrioritize follow-up and actions based on case request receipt dates, customer workflow, service level agreements and regulatory timeframes. oResponsibilities exclude collection of non-scripted information, evaluation, or interpretation of clinical information, and providing medical advice/opinion on treatment or services. o Please note that this role may require you to work in rotational shifts




Any Graduation