Managed Services - BOS - Appeals & Grievances - Manager(Operate)

Line of Service

Advisory

Industry/Sector

Not Applicable

Specialism

Managed Services

Management Level

Manager

Job Description & 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 Revenue Cycle Managed Services team will provide you with the opportunity to act as an extension of our healthcare clients' revenue cycle functions. We specialize in front, middle and back office revenue cycle functions for hospitals, medical groups, and other providers. We leverage our custom and automated workflow and quality assurance products to enable our clients to achieve better results, which ultimately allow them to provide better patient care.

To really stand out and make us fit for the future in a constantly changing world, each and every one of us at PwC needs to be a purpose-led and values-driven leader at every level. To help us achieve this we have the PwC Professional; our global leadership development framework. It gives us a single set of expectations across our lines, geographies and career paths, and provides transparency on the skills we need as individuals to be successful and progress in our careers, now and in the future.

As a Senior Manager, you'll work as part of a team of problem solvers, helping to solve complex business issues from strategy to execution. PwC Professional skills and responsibilities for this management level include but are not limited to:

• Encourage everyone to have a voice and invite opinion from all, including quieter members of the team.
• Deal effectively with ambiguous and unstructured problems and situations.
• Initiate open and candid coaching conversations at all levels.
• Move easily between big picture thinking and managing relevant detail.
• Anticipate stakeholder needs, and develop and discuss potential solutions, even before the stakeholder realises they are required.
• Contribute technical knowledge in area of specialism.
• Contribute to an environment where people and technology thrive together to accomplish more than they could apart.
• Navigate the complexities of cross-border and/or diverse teams and engagements.
• Initiate and lead open conversations with teams, clients and stakeholders to build trust.
• Uphold the firm's code of ethics and business conduct.

• A minimum of 8 to 12 years of applicable, professional work experience in appeals, grievances & Utilization management is necessary.
• Demonstrated experience in delivering training through different methods such as hands-on, virtual, and classroom settings is essential.
• A demonstrated capability to create and deliver impactful training materials, processes, and sessions is necessary.
• Excellent communication skills (verbal, written, presentation, interpersonal/relationship building) required.
• Ability to interact professionally and effectively with all levels of staff required.
• Ability to interpret complex payer & provider agreement and convey the complex information in a way that people understand.
• Excellent organizational, decision-making, problem identification and resolution, and time management skills required.
• Knowledge of NCQA regulations, state, and federal guidelines regarding the processing of member/provider
• Proficiency in MS Office applications (Word, Excel, PowerPoint, Outlook, Teams) required.
• Strong Knowledge to interpret Medical Records
• Certified in ICD10CM coding.
• Provide training on denial documentation and appeals process.
• Ability to interpret RAC and other governmental guidelines.
• Supporting policy development, Implementation, and staff education
• Recommend or educate team on policies regarding the proper use of CPT Codes, modifiers, and diagnosis codes to comply with regulations set forth by Medicare, Medicaid, Managed Care, PPO Contracts, Indemnity Insurers, and all other healthcare payers.
• Determines appropriate language for letters and train how to respond to provider grievances / appeals.

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

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