Managed Services - BOS - Appeals & Grievances - Specialist

Line of Service

Advisory

Industry/Sector

Not Applicable

Specialism

Managed Services

Management Level

Specialist

Job Description & Summary

A career in our Managed Services team will provide you an opportunity to collaborate with a wide array of teams to help our clients implement and operate new capabilities, achieve operational efficiencies, and harness the power of technology.

Our Revenue Cycle Managed Services team will provide you with the opportunity to act as an extension of our healthcare clients revenue cycle functions. We specialize in front, middle and back office revenue cycle functions for hospitals, medical groups, and other providers. We leverage our custom and automated workflow and quality assurance products to enable our clients to achieve better results, which ultimately allow them to provide better patient care.

To really stand out and make us fit for the future in a constantly changing world, each and every one of us at PwC needs to be a purpose-led and values-driven leader at every level. To help us achieve this we have the PwC Professional; our global leadership development framework. It gives us a single set of expectations across our lines, geographies and career paths, and provides transparency on the skills we need as individuals to be successful and progress in our careers, now and in the future.

As a Specialist, youll work as part of a team of problem solvers, helping to solve complex business issues from strategy to execution. PwC Professional skills and responsibilities for this management level include but are not limited to:

• Conduct self in a professional manner and take responsibility for work and commitments.
• Flex approach to meet the changing needs of teams and clients.
• Identify and make suggestions for efficiencies and improvements when performing work.
• Take action to stay current with new and evolving technology.
• Use tools, techniques and firm standard methodologies to support research, analysis and problem solving.
• Handle, manipulate and analyse data and information responsibly.
• Communicate with empathy and adapt communication style to meet the needs of the situation and audience.
• Manage expectations of stakeholders effectively.
• Embrace different points of view and welcome opposing and conflicting ideas.
• Uphold the firms code of ethics and business conduct.

JOB DESCRIPTION

To really stand out and make us fit for the future in a constantly changing world, each and every one of us at PwC needs to be a purpose-led and values-driven leader at every level. To help us achieve this we have the PwC Professional; our global leadership development framework. It gives us a single set of expectations across our lines, geographies and career paths, and provides transparency on the skills we need as individuals to be successful and progress in our careers, now and in the future.

As an AGMS Associate , youll work as part of a team of problem solvers, helping to resolve complex business issues from strategy to execution. PwC Professional skills and responsibilities for this management level include but are not limited to:

· Use feedback and reflection to develop self awareness, personal strengths and address development areas.

· Delegate to others to provide stretch opportunities, coaching them to deliver results.

· Demonstrate critical thinking and the ability to bring order to unstructured problems.

· Use a broad range of tools and techniques to extract insights from current industry or sector trends.

· Review your work and that of others for quality, accuracy and relevance.

· Know how and when to use tools available for a given situation and can explain the reasons for this choice.

· Seek and embrace opportunities which give exposure to different situations, environments and perspectives.

· Use straightforward communication, in a structured way, when influencing and connecting with others.

JOB OVERVIEW

The Specialist role is an individual contributor position that brings foundational business knowledge, problem-solving and an inquisitive mindset to create distinctive value for AGMS and its clients while creating a culture of individual ownership and accountability for high performance. A Specialist is responsible for reviewing and resolving member and provider complaints and communicating resolution to members and provider (or authorized representatives) in accordance with the standards and requirements established by the Centers for Medicare and Medicaid. The Specialist interfaces directly with: health plan Claims, Utilization Management, Network Management and Call Center professionals to collect information related to the research and analysis of appeals and grievance cases; health plan members and providers to inquire and collect additional information; Managers to efficiently and effectively manage the day-to-day operations; and Quality Assurance Specialist and A&G Trainers to improve the overall productivity and quality of the engagement team while maintaining good employee relations. All tasks related to this position are to be done in a manner consistent with AGMS policies, procedures, quality standards, customer needs and applicable local, state and federal regulations.

Years of Experience

· Minimum Years of Experience: 1+ years in healthcare, preferably health plan, with experience with member appeals, member complaints, provider payment appeals, provider payment disputes, customer service, utilization management, medical management, claims, regulatory affairs / compliance

Responsibilities:

As a Specialist , you’ll work as part of a team of problem solvers with consulting and industry experience, helping our clients solve their complex member, provider and business issues.

Specific responsibilities include, but are not limited to:

· Analyzes, evaluates and resolves member & provider appeals, disputes, grievances, and/or complaints from health plan members, providers and related outside agencies in accordance with the standards and requirements established by the Centers for Medicare and Medicaid and/or health plan. Prepares and organizes case research, notes, and documents.

· Contacts the member/provider through written and verbal communication.

· Requests, obtains and reviews medical records, notes, and/or detailed bills as appropriate. Applies contract language, benefits, and review of covered services.

· Conducts research, fact checking and analysis and recommends appropriate course of action and next steps for management review.

· Research claim / service authorization appeals and grievances using support systems to determine appeal and grievance outcomes inclusive of claims processing guidelines, provider contracts, fee schedules and system configurations to determine root cause of payment error.

· Determines appropriate language for letters and composes all correspondence and appeal/dispute and or grievances information concisely and accurately, in accordance with regulatory requirements.

· Communicates resolution to members (or authorized) representatives.

· Works with provider & member services to resolve balance bill issues and other member/provider complaints.

· Assures timeliness and appropriateness of responses per state, federal and health plan guidelines.

· Responsible for meeting production standards set by the department.

· Prepares appeal summaries, correspondence, and document findings. Include information on trends if requested.

Required Knowledge and Skills

· Strong verbal and written communication skills, including letter writing experience.

o Language skills:

§ Excellent English skills with the ability to read, comprehend, write and communicate verbally with stakeholders & customers.

§ Proficiency in Spanish as a first or second language would be preferred.

· Ability to work with firm deadlines, multi-task, set priorities and pay attention to details

· Ability to successfully interact with members, medical professionals, health plan and government representatives.

· Knowledge of operational managed care terminology. ICD-10 and CPT codes a plus

· Proficiency with Microsoft Word, Excel, and PowerPoint.

· Excellent organizational, interpersonal and time management skills.

· Must be detail-oriented and an enthusiastic team player.

· Knowledge of Pega computer system a plus.

· Preferred experience with appeals and grievances

Desired Knowledge and Skills

· Operational managed care experience (call center, appeals or claims environment).

· Health claims processing background, including coordination of benefits, subrogation, and eligibility criteria.

· Familiarity with Medicaid and Medicare claims denials and appeals processing, and knowledge of regulatory guidelines for appeals and denials.

Professional and Educational Background

· The candidate should be graduate in any discipline or an equivalent amount of related work experience is required.

· Prefer 1 year of healthcare, preferably health plan, experience in:

o Member appeals, member complaints, provider payment appeals, provider payment disputes, or

o Customer service, or

o Utilization management, or

o Medical management, or

o Claims, or

o Regulatory affairs / compliance

Additional Information

· Shift timings: Flexible to work in night shifts (US Time zone)

· Line of Service: Advisory

· Location: Hyderabad

Education (if blank, degree and/or field of study not specified)

Degrees/Field of Study required: Degrees/Field of Study preferred:

Certifications (if blank, certifications not specified)

Required Skills

Optional Skills

Desired Languages (If blank, desired languages not specified)

Travel Requirements

Not Specified

Available for Work Visa Sponsorship?

No

Government Clearance Required?

No

Job Posting End Date