Job Description

Line of Service AdvisoryIndustry/Sector Not ApplicableSpecialism Managed ServicesManagement Level Specialist & 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, 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:

• 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 firm\'s code of ethics and business conduct.

JOB DESCRIPTIONTo 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, you\'ll 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:\xc2\xb7 Use feedback and reflection to develop self awareness, personal strengths and address development areas.\xc2\xb7 Delegate to others to provide stretch opportunities, coaching them to deliver results.\xc2\xb7 Demonstrate critical thinking and the ability to bring order to unstructured problems.\xc2\xb7 Use a broad range of tools and techniques to extract insights from current industry or sector trends.\xc2\xb7 Review your work and that of others for quality, accuracy and relevance.\xc2\xb7 Know how and when to use tools available for a given situation and can explain the reasons for this choice.\xc2\xb7 Seek and embrace opportunities which give exposure to different situations, environments and perspectives.\xc2\xb7 Use straightforward communication, in a structured way, when influencing and connecting with others.JOB OVERVIEWThe 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\xc2\xb7 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 / 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:\xc2\xb7 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.\xc2\xb7 Contacts the member/provider through written and verbal communication.\xc2\xb7 Requests, obtains and reviews medical records, notes, and/or detailed bills as appropriate. Applies contract language, benefits, and review of covered services.\xc2\xb7 Conducts research, fact checking and analysis and recommends appropriate course of action and next steps for management review.\xc2\xb7 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.\xc2\xb7 Determines appropriate language for letters and composes all correspondence and appeal/dispute and or grievances information concisely and accurately, in accordance with regulatory requirements.\xc2\xb7 Communicates resolution to members (or authorized) representatives.\xc2\xb7 Works with provider & member services to resolve balance bill issues and other member/provider complaints.\xc2\xb7 Assures timeliness and appropriateness of responses per state, federal and health plan guidelines.\xc2\xb7 Responsible for meeting production standards set by the department.\xc2\xb7 Prepares appeal summaries, correspondence, and document findings. Include information on trends if requested.Required Knowledge and Skills\xc2\xb7 Strong verbal and written communication skills, including letter writing experience.o Language skills:\xc2\xa7 Excellent English skills with the ability to read, comprehend, write and communicate verbally with stakeholders & customers.\xc2\xa7 Proficiency in Spanish as a first or second language would be preferred.\xc2\xb7 Ability to work with firm deadlines, multi-task, set priorities and pay attention to details\xc2\xb7 Ability to successfully interact with members, medical professionals, health plan and government representatives.\xc2\xb7 Knowledge of operational managed care terminology. ICD-10 and CPT codes a plus\xc2\xb7 Proficiency with Microsoft Word, Excel, and PowerPoint.\xc2\xb7 Excellent organizational, interpersonal and time management skills.\xc2\xb7 Must be detail-oriented and an enthusiastic team player.\xc2\xb7 Knowledge of Pega computer system a plus.\xc2\xb7 Preferred experience with appeals and grievancesDesired Knowledge and Skills\xc2\xb7 Operational managed care experience (call center, appeals or claims environment).\xc2\xb7 Health claims processing background, including coordination of benefits, subrogation, and eligibility criteria.\xc2\xb7 Familiarity with Medicaid and Medicare claims denials and appeals processing, and knowledge of regulatory guidelines for appeals and denials.Professional and Educational Background\xc2\xb7 The candidate should be graduate in any discipline or an equivalent amount of related work experience is required.\xc2\xb7 Prefer 1 year of healthcare, preferably health plan, experience in:o Member appeals, member complaints, provider payment appeals, provider payment disputes, oro Customer service, oro Utilization management, oro Medical management, oro Claims, oro Regulatory affairs / complianceAdditional Information\xc2\xb7 Shift timings: Flexible to work in night shifts (US Time zone)\xc2\xb7 Line of Service: Advisory\xc2\xb7 Location: 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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