Health Admin Services Associate

Health Admin Services Associate

Skill Required: Claims Appeals - Claims Administration

Designation: Health Admin Services Associate

Qualifications: Any Graduation

Years of Experience: 1 to 3 years

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.

What Are We Looking For?

• Written and verbal communication
• Microsoft Excel
• Microsoft PowerPoint
• Related outsourcing operations experience
• Claims reviews/audit experience and data entry experience
• Knowledge of utilization management process and ability to interpret and apply member contracts, and member benefits
• Knowledge of ICD-9 and CPT codes, preferred
• Experience in medical or insurance field, preferred
• Requires analysis and solving of increasingly complex problems
• Interaction is with peers within Accenture before updating supervisors
• With proper guidance and oversight by Team Lead, may be tapped for precepting, training, mentoring and job shadowing duties
• Holds current and unrestricted local (PH) Registered Nurse license
• Bachelor of Science Nursing (BSN) degree
• Excellent written and verbal communication skills in English
• Must pass American English and alternate language fluency test upon hire (non-US resident) by successfully completing internal written test
• Proficiency in basic computer knowledge with the ability to learn additional computer programs
• A minimum of three (3) months of prior working experience as a Registered Nurse in a clinical setting required
• Strong customer service focus

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 and consolidates inputs for approval
• Generates the needed letters as directed by client and/or outlined in client’s procedure manual
• Assigns cases/activities and works 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
• Provides administrative support to Nurse Reviewer via case preparation, phone number verification, medical record requests and verbal call out approval notifications
• Provides administrative support of post service claims utilizing the members benefit contract and health plan guidelines
• Performs administrative tasks and work as directed by clinician or Team Lead/Operations
• Reports inventory numbers and assigns task lists under the direction of the Team Lead/Operations and as requested by the customer
• Prioritizes follow-up and actions based on case request receipt dates, customer workflow, service level agreements and regulatory timeframes
• Responsibilities exclude collection of non-scripted information, evaluation, or interpretation of clinical information, and providing medical advice/opinion on treatment or services
• Please note that this role may require you to work in rotational shifts

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.

Equal Employment Opportunity Statement: We believe that no one should be discriminated against because of their differences. All employment decisions shall be made without regard to age, race, creed, color, religion, sex, national origin, ancestry, disability status, military or veteran status, sexual orientation, gender identity or expression, genetic information, marital status, citizenship status or any other basis as protected by applicable law. Our rich diversity makes us more innovative, more competitive, and more creative, which helps us better serve our clients and our communities.