Appeals and Grievances

Job Description:- (Mandate Requirement)

• Payer Side OR Member Side.
• Appeals & Grievances

HYDERABAD ONLY

NOTE* - Not looking for Provider current experience. ONLY PAYER

Job 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 Appeals and Grievances Managed Services (AGMS) team will provide you with the opportunity to act as an extension of our healthcare clients' business office. We specialize in appeal and grievances functions and addressing member complaints for health plans and their business partners. We leverage our clients customized workflows and associated automations in conjunction with PwC’s data advanced data analysis and quality assurance processes to enable our clients to achieve better compliant results, which ultimately allows them to provide better services to their members.

Minimum Degree Required (BQ) *:

Bachelor’s Degree

Degree Preferred:

Bachelor’s Degree

Required Field(s) of Study (BQ):

Any Graduation

Preferred Field(s) of Study:

Minimum Year(s) of Experience (BQ) *: US

2+ years of experience in US Health care Payer side

Certification(s) Preferred:

NA

Required Knowledge/Skills (BQ):

• US Healthcare Experience
• Experience in Appeals & Grievances (A&G, Medicare/Medicaid)

Preferred Knowledge/Skills *:

• Strong verbal and written communication skills, including letter writing experience.
• Excellent English skills with the ability to read, comprehend, write and communicate verbally with stakeholders & customers.
• Ability to work with firm deadlines, multi-task, set priorities and pay attention to details
• Ability to successfully interact with members, medical professionals, health plan and government representatives.
• Knowledge on Appeals & Grievances and Medicare/Medicaid
• Proficiency with Microsoft Word, Excel, and PowerPoint.
• Excellent organizational, interpersonal and time management skills.
• Must be detail-oriented and an enthusiastic team player.
• Knowledge of Pega computer system a plus.

Responsibilities:

As an Associate, you’ll 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:

• 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.
• Contacts the member/provider through written and verbal communication.
• Requests, obtains and reviews medical records, notes, and/or detailed bills as appropriate. Applies contract language, benefits, and review of covered services.
• Conducts research, fact checking and analysis and recommends appropriate course of action and next steps for management review.
• 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.
• Determines appropriate language for letters and composes all correspondence and appeal/dispute and or grievances information concisely and accurately, in accordance with regulatory requirements.
• Communicates resolution to members (or authorized) representatives.
• Works with provider & member services to resolve balance bill issues and other member/provider complaints.
• Assures timeliness and appropriateness of responses per state, federal and health plan guidelines.
• Responsible for meeting production standards set by the department.
• Prepares appeal summaries, correspondence, and document findings. Include information on trends if requested.

Desired Knowledge / Skills:

• 2+ years of experience in US Health care Payer side
• 1 + years of processing experience in Appeals & Grievance
• Denial Management
• Knowledge on US Health Care, Claims Adjudication, Rework & A&G
• Experience Level: 1+ years
• Shift timings: Flexible to work in night shifts (US Time zone)