Managed Services - BOS - Senior Manager (Quality Control)

PwC

Hyderabad, Telangana
Permanent
Full-time

27 days ago

Line of Service AdvisoryIndustry/Sector Not ApplicableSpecialism Managed ServicesManagement Level Senior ManagerJob Description & Summary A career in our Advisory Acceleration Centre is the natural extension of PwC’s leading class global delivery capabilities. We provide premium, cost effective, high quality services that support process quality and delivery capability in support for client engagements.To really stand out and make us fit for the future in a constantly changing world, each and every one of us at PwC needs to be a purpose-led and values-driven leader at every level. To help us achieve this we have the PwC Professional; our global leadership development framework. It gives us a single set of expectations across our lines, geographies and career paths, and provides transparency on the skills we need as individuals to be successful and progress in our careers, now and in the future.The purpose of this role is to support a national team by providing client services related to clinical appeals and clinical denials management. This position will be responsible for working effectively with payers and providers, along with different members of the internal team of Clinicians, Nurses, Accounts Receivable Analysts, Coding team, and Physicians and internal team and client leadership.Years of Experience:Candidates with 8+ years of experience in a clinical denials, medical necessity, and business settingResponsibilities:Manages the internal clinical denial and appeals team in a manner that diligently investigates Payer denied claims;Direct overarching, results-driven activities on multiple large projects by developing the project team, assessing engagement risks throughout, driving conclusions, and reviewing / challenging the output produced by the team;Develop engagement frameworks, plans and program structure; work with client to define resource needs and managing engagement expectations;Shape and deliver various projects that exceed the expectations of our clients and our own quality criteria;Assesses the need for formal appeals of clinical denials;Ensures team appeals the rejections appropriately as per the appeals process for the provider contract;Develops and updates clinical denial policies and procedures as applicable;Reviews and audits clinical denial appeal letter documentation to ensure its sufficiency and high-quality client deliverables;Provides education including various resources to the clinical denial team in order to understand the appeals and denials clinical criteria; searches for supporting clinical evidence to support appeal arguments when existing resources are unavailable;Onboards, mentors and trains new hire clinical denial staff to policies and procedures as applicable;Adheres to appeal timelines as prescribed by payer agreements;Employs the use of different technology systems and applications to evaluate clinical, coding, and financial data;Identifies coding and clinical documentation trends related to different cases and various insurance carriers; maintains related data and monitors payer response to appeal activity;Provides information to leadership on patterns or trends associated with denials and appeals;Evaluates and adheres to all clinical and billing policies, clinical guidelines, coding guidelines and regulations of both commercial and governmental payers;Ensures clinical denial team is taking steps necessary to understand the quality assurance requirements to ensure procedural compliance and high-quality client deliverables; and,Oversees revenue cycle process improvement projects.Required Knowledge and Skills:Software/Systems Experience: InterQual, Milliman Care Guidelines and EMR (e.g. Epic, Cerner, etc.) chart review experience;Excellent clinical denial writing skills with ability to mentor and train team during the onboarding processes; and,Proficient in Microsoft Office (i.e., Word, Excel, PowerPoint, Visio, etc.).US Hospital and/or Medical Group Accounts Receivable ManagementUS Hospital and/or Medical Group Performance Reporting and KPI ImprovementUS Healthcare Revenue Cycle Performance Management ReportingUS Healthcare Commercial and Managed Care Insurance Claim Management/Billing/Claim Edit ResolutionUS Healthcare Medicare and Medicaid Insurance Claim Management/Billing/Claim Edit ResolutionUS Healthcare Denials Management (technical and clinical)US Healthcare Underpayment/Payment Variance ManagementThe Quality Control Sr. Manager in Revenue Cycle Management (RCM) Process Should have 13 years of experience and holds a crucial position tasked with ensuring the precision, effectiveness, and adherence to regulations of revenue cycle processes within the organization.
This role demands a blend of strategic acumen, leadership prowess, and an extensive comprehension of revenue cycle management methodologies.
Supervise a team of quality analysts, devise quality assurance protocols, and work closely with cross-functional teams to enhance revenue cycle operations.Key Responsibilities:
Team Leadership and Management:
Lead and manage a team of quality analysts responsible for auditing revenue cycle processes.
Provide guidance, mentorship, and training to ensure team members have the necessary skills and knowledge to perform their roles effectively.
Foster a culture of accountability, excellence, and continuous improvement within the team.Quality Assurance Strategy:
Develop and implement a comprehensive quality assurance strategy for revenue cycle processes, including billing, coding, claims processing, and collections.
Establish quality benchmarks, metrics, and Key Performance Indicators (KPIs) to measure performance and identify areas for improvement.
Conduct regular audits and reviews to assess compliance with industry regulations, organizational policies, and best practices.Process Optimization:
Collaborate with cross-functional teams, including revenue cycle management, finance, IT, and compliance, to identify process inefficiencies and implement solutions.
Streamline revenue cycle workflows to enhance efficiency, accuracy, and revenue capture.
Utilize data analytics and performance metrics to identify trends, root causes of errors, and opportunities for process optimization.Compliance and Risk Management:
Ensure compliance with regulatory requirements, such as HIPAA, HITECH, and CMS guidelines, as well as organizational policies and contractual obligations.
Identify and mitigate risks related to revenue cycle processes, including fraud, abuse, and billing errors.
Stay abreast of regulatory changes and industry trends impacting revenue cycle management.Reporting and Communication:
Prepare and present regular reports on quality assurance activities, audit findings, and performance metrics to senior leadership and stakeholders.
Communicate effectively with internal stakeholders to drive alignment, address concerns, and implement recommendations for process improvement.
Serve as a subject matter expert on revenue cycle quality assurance, providing guidance and support to internal teams as needed.Education (if blank, degree and/or field of study not specified) Degrees/Field of Study required:Degrees/Field of Study preferred:Certifications (if blank, certifications not specified)Required SkillsOptional SkillsDesired Languages (If blank, desired languages not specified)Travel Requirements Not SpecifiedAvailable for Work Visa Sponsorship? NoGovernment Clearance Required? NoJob Posting End Date

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