Managed Services Appeals and Grievances - Analyst
Managed Services Appeals and Grievances - Analyst
ApplyAt PwC, our people in finance consulting specialise in providing consulting services related to financial management and strategy. These individuals analyse client needs, develop financial solutions, and offer guidance and support to help clients optimise their financial performance, improve decision-making, and achieve their financial goals. In financial operations at PwC, you will specialise in improving the efficiency and effectiveness of financial operations within organisations. Your work will involve assessing financial processes, identify areas for improvement, and design and implement solutions to streamline financial operations, enhance controls, and reduce costs. You will be responsible for providing guidance on financial systems implementation, process automation, and financial shared services.
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.
CPA
Demonstrates some abilities and/or a proven record of success with identifying and addressing client needs:
- Responds to client and/or team requests promptly and professionally; readily offering assistance;
- Contributes to a positive, collaborative working environment;
- Seeks instruction, feedback and coaching to improve performance proactively.
- 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; and,
- Prepares appeal summaries, correspondence, and document findings. Include information on trends if requested.
Learn more about how we work: https://pwc.to/how-we-work
PwC does not intend to hire experienced or entry level job seekers who will need, now or in the future, PwC sponsorship through the H-1B lottery, except as set forth within the following policy: https://pwc.to/H-1B-Lottery-Policy.
All qualified applicants will receive consideration for employment at PwC without regard to race; creed; color; religion; national origin; sex; age; disability; sexual orientation; gender identity or expression; genetic predisposition or carrier status; veteran, marital, or citizenship status; or any other status protected by law. PwC is proud to be an affirmative action and equal opportunity employer.
Applications will be accepted until the position is filled or the posting is removed, unless otherwise set forth on the following webpage. Please visit this link for information about anticipated application deadlines: https://pwc.to/us-application-deadlines
The salary range for this position is: $49,000 - $116,000, plus individuals may be eligible for an annual discretionary bonus. For roles that are based in Maryland, this is the listed salary range for this position. Actual compensation within the range will be dependent upon the individual's skills, experience, qualifications and location, and applicable employment laws. PwC offers a wide range of benefits, including medical, dental, vision, 401k, holiday pay, vacation and more. To view our benefits at a glance, please visit the following link: https://pwc.to/benefits-at-a-glance
Managed Services Appeals and Grievances - Analyst
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PwC Recruiting: H-1B Lottery Policy
PwC currently is not hiring experienced or entry level job seekers who will need, now or in the future, PwC sponsorship through the H-1B lottery, except as set forth here.
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