Health Admin Services Analyst

Health Admin Services Analyst

To provide support to the clinical team and client team to assist in the promotion of quality member outcomes, to optimize member benefits, and to promote effective use of resources. Supports the procedures that ensure adherence to medical policy and member benefits in providing service that is medically appropriate, high quality, and cost effective.

Utilization Management: Gathers information using the appropriate client-specific telephonic screening tools. Conducts pre-review screening under the guidance and direction of US licensed health professionals. Case Management/Disease Management - Provides support functions for wellness programs, health management programs and preventative care opportunities that the member may have as part of their benefits.

Roles and Responsibilities:

• Manages incoming or outgoing telephone calls, e-Reviews, and/or faxes, including triage, opening of cases and data entry into client system.
• Determines contract; verifies eligibility and benefits.
• Conducts a thorough provider radius search in client system and follows up with provider on referrals given.
• Checks benefits for facility-based treatment.
• Obtains intake (demographic) information from caller, e-Reviews, and/or from fax. Processes incoming requests, collection of non-clinical information needed for review from providers, utilizing scripts to screen basic and complex requests for pre-certification and/or prior authorization.
• Performs data entry of contact into client systems and routes as appropriate.
• Match fax/clinical records with appropriate case.
• Consolidate inputs for approval.
• Generate the needed letters as directed by client and/or outlined in client’s procedure manual.
• Assign cases/activities and work within client’s system to facilitate workflow and productivity goals.
• Refers cases requiring clinical review to a nurse reviewer. Performs case checks and reviews to ensure case creation is complete, correct, and “nurse ready.”
• Tasks cases accurately to the correct queue.
• Conducts outbound scripted calls to providers to request clinical information as directed by clinician.
• Conducts outbound scripted calls to providers to complete approval notification process as directed by clinician.
• Performs Daily Task list maintenance activities under the direction of the Team Lead/Operations Manager and as per customer workflow.
• Provide administrative support to /Nurse Reviewer via case preparation, phone number verification, medical record requests and verbal call out approval notifications.
• Provide administrative support of post service claims utilizing the member’s benefit contract and health plan guidelines.
• Performs administrative tasks and work as directed by clinician or Team Lead/Operations. Consults clinician and Team Lead/Operations Manager timely and appropriately.

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.