Health Admin Services Associate-Voice

Accenture Solutions Pvt Ltd

About the Role

Embedding digital transformation in healthcare operations end-to-end, driving superior outcomes and value realization today, and enabling streamlined operations to serve the emerging healthcare market of tomorrow.

Key Responsibilities

• Conduct pre-service and retrospective Provider and Member Appeals for outpatient and inpatient requests.
• Review 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 route cases to client medical staff for further review when a service or admission does not meet medical necessity, place of service, or benefit criteria.
• Conduct 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.
• Review and process appeals for denied insurance claims.
• Evaluate reasons for denial, gather additional information, and make decisions on the appeal.
• Communicate with claimants.
• Analyze documentation.
• Adhere to regulatory guidelines.
• Administer health, life, and property casualty claims.
• Perform core claim processing activities such as registering claims, editing verification, claims evaluation, and examination litigation.
• Solve routine problems, largely through precedent and referral to general guidelines.
• Interact primarily within your own team and with your direct supervisor.
• Receive detailed to moderate instruction on daily work tasks and detailed instruction on new assignments.
• Make decisions that impact your own work.
• Act as an individual contributor as part of a team, with a predetermined, focused scope of work.

Requirements & Tech Stack

• Claims Appeals
• Claims Administration
• Proficiency in basic computer knowledge with the ability to learn additional computer programs.
• 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.

Qualifications

• Graduate of any college degree or High School Diploma with 6 months BPO work experience.
• At minimum 6 months of work experience.
• Excellent written and verbal communication skills in English.
• 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 is required.
• Three months is equivalent to 480 hours of working experience as an RN.
• Any Graduation