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Government Health Claims Adjudication Lead

multiple locations +view all Job No. r00182174 Full-time

Job Description

We are… 

We are a global collective of innovators applying the New every day to improve the way the world works and lives. New doesn’t mean being ahead of the curve; new is pushing forward the curve, riding the edge where the impossible meets the transformational and making it reality where it matters. Help us show the world what’s possible as you partner with clients to unlock hidden value and deliver innovative solutions. Empowered with innovative tools, continuous learning and a global community of diverse talent and perspectives, we drive success in a new business architecture that disrupts conventional practices. Our expertise spans 40+ industries across 120+ countries and impacts millions of lives every day. We turn ideas into reality.   


You are… 

As a member of Accenture’s healthcare team, you’ll be part of a team of health advisory professionals. From rapid deployments to entire transformations, you’ll deliver leading edge Medicare strategy and operations capabilities to our clients.    


As a Government Health Claims Adjudication Leader, your primary responsibilities may include:  


Medicare Operations & Claims Processing  

  • Provide Medicare Operations and Regulatory expertise to support client partners and operational teams  

  • Understand and provide direction to operational teams on end-to-end Medicare claim processing (e.g. professional/facility claims, benefit/provider configuration, rate assignments, COB etc.) 


Claims Inventory Management 

  • Oversee complete, timely, and accurate claims processing and servicing activities in compliance with regulatory agencies and client expectations in a manner that strives for operational excellence 

  • Manage and optimize work production through daily review of inventory report(s) to assess risk and current performance against target(s)  

  • Understand and develop inventory prioritization strategies (e.g. TAT, escalations, skillset, capacity planning, etc.) to actively allocate staff to critical inventories  


 Claims Quality Management & Process Improvement  

  • Identify and evaluate trends in claims denials, reimbursements, and payment discrepancies and implement targeted solutions/ mitigation strategies (e.g training and action plans) to facilitate improvements in claims processing and audit findings. 

  • Develop pre/post pay audits to monitor an improve staff productivity, financial accuracy and operational compliance  

  • Lead the submission and review of claim audits and present findings to internal and external audiences; perform additional tasks/function to facilitate audits as needed. 

  • Identify claims process improvement opportunities impacting system configuration, processing, and training, to improve staff productivity and operational compliance  


Reporting & Analytics  

  • Develop and enhance claims reporting metrics including KPIs to measure inventory, performance, quality, productivity, TAT, and other critical measures.  

  • Lead executive reporting on claims processing, denials, quality, and responses to regulatory/external audits 

  • Support ad-hoc project requests from client partners 


               Staff Management  

  • Manage a global team of claims operations staff for each client partners, include providing quarterly/yearly performance feedback, coaching, and training  

  • Oversee maintenance of policies and standard operating procedures  


Why should I join the Accenture Health team? 


  • Innovate every day. Be at the forefront of designing and delivering Medicare and other health technology solutions that push boundaries and create new opportunities for our clients.  

  • Lead with the industry’s best. Join an industry-recognized healthcare leader with more than 20,000 global healthcare professionals collaborating to drive enterprise-wide transformational projects on a global scale. Accenture has worked with more than 200 clients to deliver healthcare transformation to meet the diverse needs of patients and members.    

  • Learn and grow continuously. Harness unmatched training and professional development to help you build and advance your health, consultative and delivery skills. With learning resources, interactive classroom courses, real-life client simulations and ongoing mentoring available when you need it, you’ll expand your thinking beyond the core Workday implementation.  


Who will be successful at Accenture? 

It’s not just what you know or where you’ve been that propels success at Accenture: It’s who you are, fundamentally, as a person. We prize diversity in backgrounds and perspectives. Whatever your unique qualities, a few key traits should apply: You’re passionate about technology and motivated to apply the latest technology trends. You’re proactive and collaborative; a leader with effective communication skills. You’re driven by new challenges and are motivated to improve. You’re a creative problem solver with the flexibility to navigate uncertainty. You’re focused on the future with a desire to develop inclusive, responsible and sustainable solutions to complex challenges.   


Travel may be required for this role.  The amount of travel will vary from 0 to 100% depending on business need and client requirements. 


Here’s what you need: 

  • Minimum 5 years of health plan Medicare Claims operations (State and Federal) experience with deep functional, operational, and technical domain expertise  

  • Minimum 5 years experience in claims management, analysis, audit and/or testing oversight  

  • Bachelors Degree or equivalent (minimum 12 years) work experience. (If Associates Degree, must have minimum 6 years of work experience)


Preferred Qualifications: 

  • Experience with HealthEdge/FACETS 

  • Experience working with or leading global teams. 

  • Thrive in a diverse, fast paced environment. 

  • Participated and or led in CMS compliance audits 

  • An advanced degree in the area of specialization   

  • Effective communication skills (e.g., verbal, written, presentation, interpersonal)  

  • Proficiency in Microsoft Office suite including advanced excel skills to review, analyze and reconcile large datasets   

  • Experience in staff and process improvement positions with a history of increasing responsibility  

  • Extensive knowledge of professional and facility claims processing systems and strong analytical and deductive evaluation skills to anticipate and resolve potential claim system discrepancies. 

  • Ability to identify issues and develop and propose effective solutions  

Compensation at Accenture varies depending on a wide array of factors, which may include but are not limited to the specific office location, role, skill set, and level of experience. As required by local law, Accenture provides a reasonable range of compensation for roles that may be hired in  California, Colorado, New York or Washington as set forth below.

Information on benefits is here.

Role Location                              Annual Salary Range

California                                      $93,400 to $258,500

Colorado                                       $93,400 to $223,300

New York                                       $86,500 to $258,500

Washington                                  $99,500 to $237,800




What We Believe


We have an unwavering commitment to diversity with the aim that every one of our people has a full sense of belonging within our organization. As a business imperative, every person at Accenture has the responsibility to create and sustain an inclusive environment.


Inclusion and diversity are fundamental to our culture and core values. Our rich diversity makes us more innovative and more creative, which helps us better serve our clients and our communities. Read more here


Equal Employment Opportunity Statement

Accenture is an Equal Opportunity Employer. We believe that no one should be discriminated against because of their differences, such as age, disability, ethnicity, gender, gender identity and expression, religion or sexual orientation.

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.

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


For details, view a copy of the Accenture Equal Employment Opportunity and Affirmative Action Policy Statement.

Requesting An Accommodation

Accenture is committed to providing equal employment opportunities for persons with disabilities or religious observances, including reasonable accommodation when needed. If you are hired by Accenture and require accommodation to perform the essential functions of your role, you will be asked to participate in our reasonable accommodation process. Accommodations made to facilitate the recruiting process are not a guarantee of future or continued accommodations once hired.

If you would like to be considered for employment opportunities with Accenture and have accommodation needs for a disability or religious observance, please call us toll free at 1 (877) 889-9009, send us an email or speak with your recruiter.

Other Employment Statements

Applicants for employment in the US must have work authorization that does not now or in the future require sponsorship of a visa for employment authorization in the United States.

Candidates who are currently employed by a client of Accenture or an affiliated Accenture business may not be eligible for consideration.

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

The Company will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. Additionally, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the Company's legal duty to furnish information.


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