Skill required: HM- Utilization Management - Healthcare Management
Designation: Customer Service New Associate
Qualifications:Any Graduation
Years of Experience:0 to 1 years
About Accenture
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What would you do? Embedding digital transformation in healthcare operations end-to-end, driving superior outcomes and value realization today, and enabling streamlined operations to serve the emerging health care market of tomorrow. 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. You will be a part of the Healthcare Claims team which is responsible for the administration of health claims. This team is involved in core claim processing such as registering claims, editing & verification, claims evaluation, and examination & litigation. The Healthcare Delivery team focuses on the process of providing care to patients including hospital departments, clinical services and other functions integral to the patient journey.
What are we looking for? •Healthcare Utilization Management •Adaptable and flexible •Ability to work well in a team •Commitment to quality •Written and verbal communication •Process-orientation •Health Insurance Portability & Accountability Act (HIPAA)
Roles and Responsibilities: •In this role you are required to solve routine problems, largely through precedent and referral to general guidelines • Your primary interaction is within your own team and your direct supervisor • In this role you will be given detailed instructions on all tasks • The decisions that you make impact your own work and are closely supervised • You will be an individual contributor as a part of a team with a predetermined, narrow scope of work • Please note that this role may require you to work in rotational shifts • Manages incoming or outgoing telephone calls, eReviews, 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, eReview 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 needed letters. • 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. • Performs Daily Task list maintenance activities under the direction of the Team Lead/Operations Manager and as per customer workflow. • Provide administrative support of post service claims utilizing the member’s benefit contract and health plan guidelines. • Reports inventory numbers and assigns task lists under the direction of the Team Lead/Operations and as requested by the customer. • Prioritize follow up and actions based on case request receipt dates, customer workflow, service level agreements and regulatory timeframes.