Line of Service

Advisory

Industry/Sector

Technology

Specialism

Managed Services

Management Level

Specialist

Job Description & Summary

At PwC, our people in operations consulting specialise in providing consulting services on optimising operational efficiency and effectiveness. These individuals analyse client needs, develop operational strategies, and offer guidance and support to help clients streamline processes, improve productivity, and drive business performance.

In operations and solutions at PwC, you will focus on providing consulting services to optimise overall operational performance and develop innovative solutions. You will work closely with clients to analyse operational processes, identify areas for improvement, and develop strategies to enhance productivity, quality, and efficiency. Working in this area, you will provide guidance on implementing technology solutions, process automation, and operational excellence frameworks.

You are a reliable, contributing member of a team. In our fast-paced environment, you are expected to adapt, take ownership and consistently deliver quality work that drives value for our clients and success as a team.

Examples of the skills, knowledge, and experiences you need to lead and deliver value at this level include but are not limited to:

Apply a learning mindset and take ownership for your own development.Appreciate diverse perspectives, needs, and feelings of others.Adopt habits to sustain high performance and develop your potential.Actively listen, ask questions to check understanding, and clearly express ideas.Seek, reflect, act on, and give feedback.Gather information from a range of sources to analyse facts and discern patterns.Commit to understanding how the business works and building commercial awareness.Learn and apply professional and technical standards (e.g. refer to specific PwC tax and audit guidance), uphold the Firm's code of conduct and independence requirements.

Job Summary - 

A career in our Managed Services team will provide you an opportunity to collaborate with a wide array of teams to help our clients implement and operate new capabilities, achieve operational efficiencies, and harness the power of technology. Our Appeals and Grievances Managed Services (AGMS) team will provide you with the opportunity to act as an extension of our healthcare clients' business office. We specialize in appeal and grievances functions and addressing member complaints for health plans and their business partners. We leverage our clients’ customized workflows and associated automations in conjunction with PwC’s data advanced data analysis and quality assurance processes to enable our clients to achieve better compliant results, which ultimately allows them to provide better services to their members.

Minimum Degree Required (BQ) *:

Bachelor’s Degree

Degree Preferred:  

Bachelor’s Degree

Required Field(s) of Study (BQ):  

Any Graduate

Preferred Field(s) of Study:

Any Graduate

Minimum Year(s) of Experience (BQ) *: US

1 + years of Payer side experience

Certification(s) Preferred:

 NA

Required Knowledge/Skills (BQ):

 Strong verbal and written communication skills, including letter writing experience.Language skills: Excellent English skills with the ability to read, comprehend, write and communicate verbally with stakeholders & customers.Ability to work with firm deadlines, multi-task, set priorities and pay attention to detailsAbility to successfully interact with members, medical professionals, health plan and government representatives.Knowledge of operational managed care terminology. ICD-10 and CPT codes a plusProficiency with Microsoft Word, Excel, and PowerPoint.Excellent organizational, interpersonal and time management skills.Must be detail-oriented and an enthusiastic team player.Knowledge of Pega computer system a plus.Preferred experience with appeals and grievances

Preferred Knowledge/Skills *:

Job Description Summary

Insurance Follow-Up: Contact insurance companies via phone, email, or online portals to follow up on outstanding claims. Identify and resolve issues causing payment delays, such as claim denials or underpayments. Verify claim status, appeal denied claims and resubmit claims when necessary.

Documentation and Reporting: Maintain accurate and detailed documentation of all communications and actions taken. Update account information and billing systems with payment details and follow-up notes. Generate reports on accounts receivable status, aging trends, and collection efforts.

Compliance and Regulations: Adhere to HIPAA regulations and guidelines to ensure patient confidentiality and data security. Stay informed about insurance policies, billing guidelines, and Medicare policies.

Team Collaboration: Collaborate with internal departments, to work on the Medicare -appeals and grievance requests.

Medicare & Medicaid Appeals & GrievancesMember appeals, Grievances, Dismissal, Pre-Service Appeals, Post Services Appeals. member complaints, provider payment appeals, provider payment disputesKnowledge on the CMS and Hospital & Physicians BillingHIPAA

Required Knowledge and Skills

Proven experience (1+ years) in US healthcare Payer side. Strong understanding of Medicare /medical billing processes, insurance claims, and reimbursement methodologies Excellent communication skills with the ability to effectively interact with insurance companies, patients, and internal stakeholders. Attention to detail and ability to prioritize tasks to meet deadlines. Knowledge of medical coding (ICD-10, CPT) is a plus. Experience Level: 0 to 1 years. Shift timings: Flexible to work in night shifts (US Time zone) Preferred Qualification: Bachelor’s degree / Any Graduate

Education (if blank, degree and/or field of study not specified)

Degrees/Field of Study required:

Degrees/Field of Study preferred:

Certifications (if blank, certifications not specified)

Required Skills

Optional Skills

Accepting Feedback, Accepting Feedback, Active Listening, Automation Solutions, Business Process Improvement, Communication, Competitive Advantage, Cost Efficiency, Demand Management, Emerging Technologies, Emotional Regulation, Empathy, Inclusion, Intellectual Curiosity, Lean Process Improvement, Operating Model, Operational Analysis, Operational Excellence, Operational Support and Analysis, Operations Management, Operations Process Improvement, Operations Strategy, Operations Support, Optimism, Process Data Collection {+ 9 more}

Desired Languages (If blank, desired languages not specified)

Travel Requirements

Not Specified

Available for Work Visa Sponsorship?

No

Government Clearance Required?

No

Job Posting End Date