Line of Service AdvisoryIndustry/Sector TechnologySpecialism Managed ServicesManagement Level Senior AssociateJob 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.As an AGMS Senior Associate, you'll work as part of a team of problem solvers, helping to resolve complex business issues from strategy to execution. PwC Professional skills and responsibilities for this management level include but are not limited to:Use feedback and reflection to develop self awareness, personal strengths and address development areas.Delegate to others to provide stretch opportunities, coaching them to deliver results.Demonstrate critical thinking and the ability to bring order to unstructured problems.Use a broad range of tools and techniques to extract insights from current industry or sector trends.Review your work and that of others for quality, accuracy and relevance.Know how and when to use tools available for a given situation and can explain the reasons for this choice.Seek and embrace opportunities which give exposure to different situations, environments and perspectives.Use straightforward communication, in a structured way, when influencing and connecting with others.JOB OVERVIEWThe Senior Specialist role is an individual contributor position that brings foundational business knowledge, problem-solving and an inquisitive mindset to create distinctive value for AGMS and its clients while creating a culture of individual ownership and accountability for high performance. A Specialist is responsible for reviewing and resolving member and provider complaints and communicating resolution to members and provider (or authorized representatives) in accordance with the standards and requirements established by the Centers for Medicare and Medicaid. The Senior Specialist interfaces directly with: health plan Claims, Utilization Management, Network Management and Call Center professionals to collect information related to the research and analysis of appeals and grievance cases; health plan members and providers to inquire and collect additional information; Managers to efficiently and effectively manage the day-to-day operations; and Quality Assurance Specialist and A&G Trainers to improve the overall productivity and quality of the engagement team while maintaining good employee relations. All tasks related to this position are to be done in a manner consistent with AGMS policies, procedures, quality standards, customer needs and applicable local, state and federal regulations.Years of ExperienceMinimum Years of Experience: 1+ years in healthcare, preferably health plan, with experience with member appeals, member complaints, provider payment appeals, provider payment disputes, customer service, utilization management, medical management, claims, regulatory affairs / complianceResponsibilities:As a Senior Specialist, 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.Required Knowledge and SkillsOperational managed care experience (call center, appeals or claims environment).Strong verbal and written communication skills, including letter writing experience.Language skills:Excellent English skills with the ability to read, comprehend, write and communicate verbally with stakeholders & customers.Proficiency in Spanish as a first or second language would be preferred.Ability to work with firm deadlines, multi-task, set priorities and pay attention to detailsAbility to successfully interact with members, medical professionals, health plan and government representatives.Knowledge of operational managed care terminology. ICD-10 and CPT codes a plusProficiency 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.Preferred experience with appeals and grievancesDesired Knowledge and SkillsHealth claims processing background, including coordination of benefits, subrogation, and eligibility criteria.Familiarity with Medicaid and Medicare claims denials and appeals processing, and knowledge of regulatory guidelines for appeals and denials.Professional and Educational BackgroundThe candidate should be graduate in any discipline or an equivalent amount of related work experience is required.Prefer 2+ years of healthcare, preferably health plan, experience in:Member appeals, member complaints, provider payment appeals, provider payment disputes, orCustomer service, orUtilization management, orMedical management, orClaims, orRegulatory affairs / complianceAdditional InformationShift timings: Flexible to work in night shifts (US Time zone)Experience Level : 5-8 years.Mode of working: Work from officeLine of Service: AdvisoryDesignation: Senior AssociateLocation: HyderabadEducation (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
