Job Description

Line of Service AdvisoryIndustry/Sector Not ApplicableSpecialism Managed ServicesManagement Level Associate & 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 Virtual Business Office team will provide you with the opportunity to act as an extension of our healthcare clients\' business office. We specialize in revenue cycle functions and remediating aged 3rd party accounts receivable 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 Associate, you\'ll 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:Years of ExperienceMinimum 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 / complianceResponsibilities:As a Specialist, you\xe2\x80\x99ll 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 SkillsStrong verbal and written communication skills, including letter writing experience.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 detailsAbility to successfully interact with members, medical professionals, health plan and government representatives.Knowledge of operational managed care terminology. ICD-10 and CPT codes a plusProficiency 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 grievancesDesired Knowledge and SkillsOperational 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 BackgroundThe 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:Member appeals, member complaints, provider payment appeals, provider payment disputes, orCustomer service, orUtilization management, orMedical management, orClaims, orRegulatory affairs / complianceAdditional InformationShift timings: Flexible to work in night shifts (US Time zone)Experience Level : 3-5 years.Mode of working: Work from officeLine of Service: AdvisoryDesignation: AssociateLocation: HyderabadEducation (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 SkillsOptional SkillsDesired Languages (If blank, desired languages not specified)Travel Requirements Not SpecifiedAvailable for Work Visa Sponsorship? NoGovernment Clearance Required? NoJob Posting End Date

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