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Managed Services - BOS - Appeals & Grievances - Associate-Quality Analyst - Operate

Location Telangana, India Category Accounting, Assurance and Audit Job Id 604739WD Associate

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JOB DESCRIPTION
At PwC, our people in operations consulting specialise in providing consulting services on optimising operational efficiency and effectiveness. These individuals analyse client needs, develop operational strategies, and offer guidance and support to help clients streamline processes, improve productivity, and drive business performance. In operations and solutions at PwC, you will focus on providing consulting services to optimise overall operational performance and develop innovative solutions. You will work closely with clients to analyse operational processes, identify areas for improvement, and develop strategies to enhance productivity, quality, and efficiency. Working in this area, you will provide guidance on implementing technology solutions, process automation, and operational excellence frameworks.

Driven by curiosity, you are a reliable, contributing member of a team. In our fast-paced environment, you are expected to adapt to working with a variety of clients and team members, each presenting varying challenges and scope. Every experience is an opportunity to learn and grow. You are expected to take ownership and consistently deliver quality work that drives value for our clients and success as a team. As you navigate through the Firm, you build a brand for yourself, opening doors to more opportunities.

Examples of the skills, knowledge, and experiences you need to lead and deliver value at this level include but are not limited to:

  • Apply a learning mindset and take ownership for your own development.
  • Appreciate diverse perspectives, needs, and feelings of others.
  • Adopt habits to sustain high performance and develop your potential.
  • Actively listen, ask questions to check understanding, and clearly express ideas.
  • Seek, reflect, act on, and give feedback.
  • Gather information from a range of sources to analyse facts and discern patterns.
  • Commit to understanding how the business works and building commercial awareness.
  • Learn and apply professional and technical standards (e.g. refer to specific PwC tax and audit guidance), uphold the Firm's code of conduct and independence requirements.

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 Graduate

Preferred Field(s) of Study:

Any Graduate

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

 3 +years of Payer side experience

Certification(s) Preferred:

 NA

Required Knowledge/Skills (BQ):

  •  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.
  • 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 of operational managed care terminology. ICD-10 and CPT codes a plus
  • 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.
  • Preferred experience with appeals and grievances

Preferred Knowledge/Skills *:

The quality control analyst conducts quality control audits of Medicare Appeals and Grievance(A&G) and assures company and client standards are maintained and the integrity of client services are preserved. The Quality Control Analyst will perform a variety of functions including, but not limited to: reviewing and monitoring accounts, identifying problems, analyzing trends and suggesting recommendations for improvements. This role consults with and takes direction from the Continuous Improvement Specialist to resolve quality and efficiency issues that may occur on any given project.

  • Knowledge on the quality model
  • Medicare & Medicaid Appeals & Grievances
  • Member appeals, Grievances, Dismissal, Pre-Service Appeals, Post Services Appeals. member complaints, provider payment appeals, provider payment disputes
  • Knowledge on the CMS and Hospital & Physicians Billing
  • HIPAA
  • QC tools and Root cause analysis


Responsibilities: 

  • As Quality Control Analyst specific responsibilities include but are not limited to:
  • Performs quality control audits, reviews and monitors accounts.
  • Identifies problems, analyzes cause and effect, and suggests recommendations for improvement.
  • Provides daily constructive feedback based on account notation.
  • Identifies areas of weakness and communicates recommendations on changes and improvement to Continuous Improvement Specialists;
  • Document findings of analysis. May prepare reports and suggests recommendations of implementation of new systems, procedures or organizational changes;
  • Relies on specific instructions and pre-established guidelines to perform the functions of the job;
  • Possesses ability to be confidential; Supports company compliance by demonstrating adherence to all relevant compliance policies and procedures; demonstrates knowledge of HIPAA Privacy and Security Regulations as evidenced by appropriate handling of sensitive information;
  • Consults and collaborates with Continuous Improvement Specialist to identify and assess training needs based on work audited;
  • Participate in quality control meetings;
  • Possesses considerable leadership skills, fostering an atmosphere of trust; seeks diverse views to encourage improvement and innovation; coaches and develops staff through timely and meaningful written feedback;
  • Possesses a cooperative and positive attitude toward management and co-workers by responding politely and professionally and being a valued team player; and,
  • Exemplifies extensive knowledge of the hospital revenue cycle with specialization in healthcare billing, follow-up, and the account resolution process to include, but not limited to: claims submission, acceptance, and adjudication, transaction reviews, adjustment posting, identification of patient responsibility, etc.
  • 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.
  • Prepares appeal summaries, correspondence, and document findings. Include information on trends if requested.
  • Prepare Quality reports


Required Knowledge and Skills:
 

  • Good analytical skills
  • Able to document problems and assist in their resolution.
  • Demonstrated ability exceeding all established department/client quality and productivity standards;
  • Proven ability to lead by example and foster mentoring relationships.
  • Strong written and oral communication skills.
  • Computer and internet literate in an MS Office environment; and,
  • Ability to establish and maintain effective working relationships.
  • US Healthcare – Medicare Appeals and Grievances(A&G)
  • US Healthcare Medicare and Medicaid Insurance Claim Management/Billing/Claim Edit Resolution
  • Experience Level: 3+ years (Payer side).
  • Shift timings: Flexible to work in night shifts (US Time zone)
  • Preferred Qualification: Bachelor’s degree


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