Skill required: Claims Appeals

• Claims Administration

Designation: Health Admin Services Senior Analyst

Qualifications: Any Graduation **Years of Experience:**5 to 8 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 Inter Qual), 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 3 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.

• Maintains active USRN Licensure.

• Responsible for notifying Team Lead, Manager, and/or Compliance Department immediately of any expiration or change in status of active USRN licensure. Does not perform clinical duties unless active licensure is documented and on file within the PMO department.

• Adheres to production and quality metrics.

• 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 Diploma Roles and Responsibilities: •In this role you are required to do analysis and solving of increasingly complex problems

• Your day to day interactions are with peers within Accenture

• You are likely to have some interaction with clients and/or Accenture management

• You will be given minimal instruction on daily work/tasks and a moderate level of instruction on new assignments

• Decisions that are made by you impact your own work and may impact the work of others

• In this role you would be an individual contributor and/or oversee a small work effort and/or team

• Please note that this role may require you to work in rotational shifts

Any Graduation

About Accenture

Accenture is a leading global professional services company that helps the world’s leading businesses, governments and other organizations build their digital core, optimize their operations, accelerate revenue growth and enhance citizen services—creating tangible value at speed and scale. We are a talent- and innovation-led company with approximately 791,000 people serving clients in more than 120 countries. Technology is at the core of change today, and we are one of the world’s leaders in helping drive that change, with strong ecosystem relationships. We combine our strength in technology and leadership in cloud, data and AI with unmatched industry experience, functional expertise and global delivery capability. Our broad range of services, solutions and assets across Strategy & Consulting, Technology, Operations, Industry X and Song, together with our culture of shared success and commitment to creating 360° value, enable us to help our clients reinvent and build trusted, lasting relationships. We measure our success by the 360° value we create for our clients, each other, our shareholders, partners and communities.
Visit us at www.accenture.com

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