Skill required: HM- Utilization Management - Healthcare Management
Designation: Health Clinical Services New Associate
Qualifications:Any Graduation
Years of Experience:0 to 1 years
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What would you do? 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. ? Gathers information and 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? Requires solving of routine problems, largely through precedent and referral to general guidelines. ? Interaction is within own team and direct superviso •Requires detailed to moderate level of instruction on daily work tasks ••Individual contributor as a part of a team, with a predetermined, focused scope of work. Working Conditions ? Able and willing to work U.S. time and as needed, overtime hours (i.e., night shift). ? Employees must be able and willing to travel to and work from locations determined at the discretion of project leadership. Accenture Confidential ? Additional tasks not indicated may be assigned by immediate supervisor/project manager/leadership. ? Some travel may be required over the course of the role. ? Cyclical work shift including work hours at night and weekends. ? Overtime and On-Call may be required. ? Client location holidays are observed instead of local country holidays.
Roles and Responsibilities: Following the Procedures Manual: ? Provides intake and prepare prior authorization requests for clinical review from Providers. ? Checks Member’s eligibility and plan benefits. ? Determines if requested service or case requires prior authorization review, intake processing, and/or clinical review. Creates cases for intake processing and prior authorization, and routes for clinical review as needed. ? Data entry of contacts into client systems and route as appropriate. ? Adheres to turnaround times in accordance with client requirements and regulatory and accreditation standards. ? Performs administrative tasks and work as directed by clinician, customer and/or Team Lead/Operations. Consults clinician and Team Lead/Operations Manager appropriately and in a timely manner. ? Responsibilities exclude collection of non-scripted information, evaluation or interpretation of clinical information, and providing medical advice/opinion on treatment or services. ? The work may be subject to applicable accreditation and regulatory standards and requirements and as such the associates will strictly follow department guidelines and tools to conduct their job requirements. ? Uses available resources to understand contractual and regulatory compliance requirements and reports suspected compliance issues on the day of discovery to a Team Lead, Manager, and/or the Compliance Department. ? Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards. ? Responsible for reporting known or suspected data breaches on the day of discovery to a Team Lead •Job Requirements • Preferred 2 or 4-year university degree. • Required a high school diploma or general equivalency diploma with 1-3 years of customer service and/or contact center experience. • Proficient analysis and problem solving capabilities. • Proficient critical thinking skills to resolve customer complex inquiries. • Attention to details, ability to prioritize and multi-task. • Excellent written and verbal communication skills in English, required. o Ability to understand language nuances, intonation, accent and inference in spoken and written American English. o Must pass American English and alternate language fluency test (“Test”) upon hire (non-US resident) by successfully completing internal written test. • Basic computer knowledge with the ability to learn additional computer programs, required. Experience/Skills Preferred ? Ability to accurately enter data from various referral forms and facsimiles.