Skill required: Claims Appeals - Claims Administration
Designation: Health Admin Services Analyst
Qualifications:Any Graduation
Years of Experience:3 to 5 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 784,000 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 Embedding digital transformation in healthcare operations end-to-end, driving superior outcomes and value realization today, and enabling streamlined operations to serve the emerging health care market of tomorrow Claims Appeals involves reviewing and processing appeals for denied insurance claims. This includes evaluating the reasons for denial, gathering additional information, and making decisions on the appeal. The goal is to ensure fair and accurate resolution of claims. Responsibilities include communicating with claimants, analyzing documentation, and adhering to regulatory guidelines. This role is essential for maintaining trust and satisfaction in the claims process. Includes the administration of health, life, and property & causality claims. Includes activities involved in core claim processing such as registering claims, editing & verification, claims evaluation, and examination & litigation.
What are we looking for
- Conduct pre-service and retrospective Provider and Member Appeals for outpatient and inpatient requests. Reviews service requests to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.
- Utilize client specific criteria sets (e.g., Milliman or InterQual), applicable client specific medical policy and client clinical guidelines for decision making to either approve, request for additional clinical information or summarize and route to Client s nursing reviewer and/or Client s medical staff for review.
- Accurately routes cases to client medical staff for further review when a service or admission does not meet medical necessity, place of service, or benefit criteria.
- Responsible for conducting medical management review activities which require the review of clinical information against client specific criteria as noted above but excludes denial determinations.
- Ensure member access to medically necessary, quality healthcare in a cost-effective setting according to contract. Consult with clinical reviewers and/or U.S.-licensed medical directors to ensure medically appropriate, high-quality, cost-effective care throughout the medical management process.
- Graduate of any college degree
- At minimum 1 year experience or related Accenture or other outsourcing experience or returning CL12 or CL11 employee (including meeting or exceeding currently published quality and productivity standards and have passed the promotion eligibility and certification requirements).
- Excellent written and verbal communication skills in English.
- Must pass American English and alternate language fluency test (Test) upon hire (non-US resident). For voice accounts, must pass US Berlitz B2 level or Versant score of 58 or any language proficiency equivalence.
- Proficiency in basic computer knowledge with the ability to learn additional computer programs.
- Holds current and unrestricted local Registered Nurse license.
- Bachelor of Science Nursing (BSN) degree or General Nursing & Midwifery (GNM) Diploma or Basic Bachelor of Science (BSC) in Nursing degree or Associate Nursing Degree or Nursing Diploma
- A minimum of three (3) months of prior working experience as a Registered Nurse in a clinical setting required.
- Three months is equivalent to 480 hours of working experience as an RN.
- Work experience as a Registered Nurse means holding an active RN license Roles and Responsibilities:
- In this role you are required to do analysis and solving of lower-complexity problems
- Your day to day interaction is with peers within Accenture before updating supervisors
- In this role you may have limited exposure with clients and/or Accenture management
- You will be given moderate level instruction on daily work tasks and detailed instructions on new assignments
- The decisions you make impact your own work and may impact the work of others
- You will be an individual contributor as a part of a team, with a focused scope of work
- Please note that this role may require you to work in rotational shifts
