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 world’s 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? Review providers’ requests for claims review and any associated clinical documentation/medical records attached, prepped and documented by the Claims team. ? Determine if complete clinical information for medical necessity review is attached/submitted. Prepare to return to claims team if incomplete documentation is received. ? Determine if the retrospective request can be approved by RN or if BSC Medical Director review is required ? Consult with clinical reviewers and/or U.S. licensed medical directors as needed to ensure medically appropriate care throughout the process. If no denial or modification of the request is involved and RN can approve services, RN will document appropriate determination into the database and send it back to claims department who will issue the letter ? 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.
What are we looking for? 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 ? 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: 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 Provider’s 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.