Managed services Appeals and Grievances - Sr. Analyst
Managed services Appeals and Grievances - Sr. 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.
Focused on relationships, you are building meaningful client connections, and learning how to manage and inspire others. Navigating increasingly complex situations, you are growing your personal brand, deepening technical expertise and awareness of your strengths. You are expected to anticipate the needs of your teams and clients, and to deliver quality. Embracing increased ambiguity, you are comfortable when the path forward isn’t clear, you ask questions, and you use these moments as opportunities to grow.
Examples of the skills, knowledge, and experiences you need to lead and deliver value at this level include but are not limited to:
- Respond effectively to the diverse perspectives, needs, and feelings of others.
- Use a broad range of tools, methodologies and techniques to generate new ideas and solve problems.
- Use critical thinking to break down complex concepts.
- Understand the broader objectives of your project or role and how your work fits into the overall strategy.
- Develop a deeper understanding of the business context and how it is changing.
- Use reflection to develop self awareness, enhance strengths and address development areas.
- Interpret data to inform insights and recommendations.
- Uphold and reinforce professional and technical standards (e.g. refer to specific PwC tax and audit guidance), the Firm's code of conduct, and independence requirements.
CPA
Demonstrates thorough abilities and/or a proven record of success as a team leader:
- Creates a positive environment by monitoring workloads of the team while meeting client expectations and respecting the work-life quality of team members;
- Provides candid, meaningful feedback in a timely manner; keeping leadership informed of progress and issues;
- Answers questions and providing direction to less-experienced staff;
- 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: $58,000 - $161,000, 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 - Sr. Analyst
Apply-
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.
Learn more -
Experienced recruiting process and FAQ
Learn more about our experienced recruiting process, what to expect during the interview experience, firm benefits and more.
Learn more -
Live and work flexibly
At PwC, it’s about being flexible for what matters most. Our work model allows for this through our hybrid way of working.
Learn more -
-
Well-being support
The firm offers a comprehensive set of benefits around mental health and well-being through our Be Well, Work Well initiatives.
Learn more
Job alerts
Receive email alerts when jobs become available and match your specified area(s) of interest.
-
Top Reasons to work at PwC
Explore the top reasons to work at PwC.
-
Generative AI
Our approach to bringing generative AI to businesses is rooted in building trust and delivering outcomes.