Health Clinical Services Senior Analyst

Skill required: HM- Utilization Management - Healthcare Management
Designation: Health Clinical Services Senior Analyst
Qualifications:Any Graduation
Years of Experience:5 to 8 years
About Accenture
Accenture is a global professional services company with leading capabilities in digital, cloud and security.Combining unmatched experience and specialized skills across more than 40 industries, we offer Strategy and Consulting, Technology and Operations services, and Accenture Song all powered by the worlds largest network of Advanced Technology and Intelligent Operations centers. Our 699,000 people deliver on the promise of technology and human ingenuity every day, serving clients in more than 120 countries. We embrace the power of change to create value and shared success for our clients, people, shareholders, partners and communities.Visit us at www.accenture.com
What would you do? Responsible to collaborate with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources. Promotes medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting by utilizing the applicable medical policy and industry standards, accurately interpreting benefits and managed care products, and may steer members to appropriate providers, programs or community resources. Works with medical directors in interpreting appropriateness of care. Ensures compliance with Accenture and Client policies at all times. Support the procedures that ensure adherence to medical policy and industry standards. 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? Holds current and unrestricted US Registered Nurse license. ? Holds state specific RN licensure as required ? Bachelor of Science Nursing (BSN) degree or General Nursing & Midwifery (GNM) Diploma or Basic Bachelor of Science (BSC) in Nursing degree or Associate Nursing Degree or Nursing Diploma ? A minimum of three (3) months of prior working experience as a Registered Nurse in a clinical setting and 1 year experience with Utilization Management Prior Authorization business process outsourcing (BPO) required, or returning CL 10 employee with 3 months prior working experience as a Registered Nurse. o Three months is equivalent to 480 hours of working experience as an RN o Working experience as a Registered Nurse means holding an active RN license and providing direct patient care o Clinical setting includes inpatient hospital, outpatient hospital or clinic. ? Excellent written and verbal communication skills in English ? Must pass an American English and alternative language fluency test upon hire (non-US resident) ? Must pass US Berlitz level B2 (or equivalent such as IELTS, TOEFL, Versant) upon hire (non-US resident) ? Proficiency in basic computer knowledge with the ability to learn additional computer programs Requires analysis and solving of increasingly complex problems. ? Interaction is with peers within Accenture before updating supervisors. Likely has some interaction with clients and/or Accenture management. ? Independently perfor
Roles and Responsibilities: The following work is to be performed by an RN who is licensed in one of the fifty U.S. states or in the District of Columbia. ? Following the Procedures Manual, will apply client internal review criteria, medical policy, and other clinical guidelines to make medical necessity decisions. ? Conduct prior authorization initial clinical review for inpatient and/or outpatient procedures/services based on medical necessity of inpatient admissions, outpatient services, and/or focused surgical and diagnostic procedures, based on client assignment. ? Review Providers prior authorization request and any associated clinical documentation/medical records and any associated patient history and/or notes entered by non-clinical Intake Team related to services requested ? Determine if sufficient documentation exists or if lack of information call/letter to Provider is required. Trigger the action to send letter to Provider, if necessary ? Determine if prior authorization request can be approved by RN or if BSC Medical Director is required ? If no denial of or modification of the request is involved and RN can approve services, send approval letter to Provider and/or Member. Update case with determination outcome, claim payment instructions, and applicable notes, and close case ? If the RN cannot approve the services and BSC Medical Director review is required, route case to BSC Medical Director. Upon completion of BSC Medical Director review, update case with BSC Medical Director determination outcome, claim payment instructions, and applicable notes. Trigger to send determination letter to Provider and/or Member. ? Additional tasks may be assigned by your Immediate Supervisor/Project Manager ? The work maybe subject to applicable accreditation and regulatory standards and requirements and as such the associate 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 (including suspected data breaches) on the day of discovery to a Team Lead, Manager, and/or the Compliance Department. ? Ensures compliance with Accenture and Client policies at all times. ? Maintains active USRN licensure. ? Responsible to notify Team Lead, Manager, and/or Compliance Department immediately of any expiration or change in status of active USRN licensure. Does not perform clinical duties unless active licensure is documented and on file within the PMO department. ? Adheres to production and quality metrics.