Healthcare Claims Appeals Analyst

Job description

Health Admin Services Analyst Skill required: Claims Appeals - Claims Administration Designation: Health Admin Services Analyst Qualifications: BCom/Bachelor of Arts/BMM Years of Experience: 3 to 5 years Language - Ability: English(Domestic) - Intermediate 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 784,000 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? The SME serves as a functional expert responsible for providing guidance on complex cases. ensuring regulatory compliance and driving process improvements. The role acts as a bridge- between operations. quality, and leadership teams by offering expertise in appeals and grievance handling, resolving escalations. and enhancing team performance. Serve as the primary point of contact for complex and escalated appeals and grievance cases. Provide guidance on case handling, policy interpretation, and decision making. Ensure accurate application of regulatory guidelines and business rules. C Case Review \& Resolution: Review and validate high-risk, sensitive, and complex cases. Ensure proper documentation, investigation, and resolution of appeals and grievances. Conduct root cause analysis for recurring issues and recommend corrective actions. Compliance \& Quality Assurance - Ensure adherence to CMS regulations and internal policies. Maintain HIPAA compliance and protect data confidentiality. Participate in quality audits arKI support internal and external audit activities. Provide feedback to improve process accuracy and effectvieness. Training \& Knowledge Sharing - Train new hires and provide ongoing coaching to team members. Develop and update SOPs, job aids, and training materials. Communicate policy changes. regulatory updates. and process improvements. Stakeholder Support Collaborate with cross.-functional teams including Claims. Enrollment Billing, and Provider teams. Act as an escalation resource for team leads and managers. Communicate case status and resolutions with internal and external stakeholders. Process Improvement \& Reporting - Identify process gaps and recommend improvement opportunities. Analyze appeals and grievance trends to reduce errors and complaints. Support reporting related to quality metrics. compliance, and operational performance. What are we looking for? Strong expertise in Appeals and Grievances (A\&G) processes. Depth knowledge of healthcare regulations, compliance requirements. and industry standards. Excellent analytical, problem-solving, and decision-making skills. Strong communication, coaching, and training capabilities. Attention to detail with a focus on accuracy and quality. Ability to manage complex. sensitive, and high-priority cases effectively. Roles and Responsibilities: •In this role you are required to do analysis and solving of lower-complexity problems • Your day to day interaction is with peers within Accenture before updating supervisors • In this role you may have limited exposure with clients and/or Accenture management • You will be given moderate level instruction on daily work tasks and detailed instructions on new assignments • The decisions you make impact your own work and may impact the work of others • You will be an individual contributor as a part of a team, with a focused scope of work • Please note that this role requires you to work in US Shift time. No morning or rotational shifts