Job Description

You will be responsible in providing support to the clinical team and client team to assist in the promotion of quality member outcomes, to optimize member benefits, and to promote effective use of resources

• Determine customer eligibility by reviewing contractual language and medical documentation, interpret information and make decisions based on facts presented.

• Assess medical appropriateness of claims submitted, and adjust claims as needed.

• Pay all covered claims accurately and timely.

• Execute on all client and provider SLA agreements.

• Attain individual and team quality and productivity targets.

• Manage both new claims and open claims equally and maintains decision turnaround times.

• Understand the client’s operations and corporate compliance, policies and procedures and best practices.

• Stay abreast of ongoing trainings associated with role and business unit objectives.

• Manages incoming or outgoing telephone calls and/or faxes, including triage, opening of cases and data entry into client system

• Determines contract; verifies eligibility and benefits.


• BS Nursing graduate with PH RN license • Minimum 3 months clinical experience in health insurance, hospital administration, and / or medical office management setting is preferred. • Excellent written and verbal communication skills in English • Basic computer knowledge with the ability to learn additional computer programs

All employment decisions shall be made without regard to age, race, creed, color, religion, sex, national origin, ancestry, disability status, veteran status, sexual orientation, gender identity or expression, genetic information, marital status, citizenship status or any other basis as protected by federal, state, or local law.

Job candidates will not be obligated to disclose sealed or expunged records of conviction or arrest as part of the hiring process.

Accenture is committed to providing veteran employment opportunities to our service men and women.

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