Operations is one of four services that make up one Accenture -the others are Strategy and Consulting, Interactive and Technology.

A Medical Serices Clinician Senior Analyst is part of the Expert Resource Team supporting Voluntary Benefit Claims Teams supporting a large Group Insurance Business contract. This Clinician Senior Analyst will collaborate with healthcare providers members to optimize member benefits. Adhere to medical policy and provide medically appropriate, high quality, cost effective service. Assess medical necessity of inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services and appropriateness of treatment setting by utilizing the applicable medical policy and industry standards. Pre review screening under the guidance of US licensed health professionals.

The Clinician's duties and skills required include but are not limited to the following:

• Review and assessment of primarily complex illness and injury claims
• Process incoming requests, collection of information needed for review from providers, utilizing scripts to screen basic and complex requests for pre certification and or prior authorization.
• Verify benefits and or eligibility information.
• Check benefits for facility based treatment.
• Complete review of pended claims utilizing Client screening tools post service for Medical Necessity or Contractual Reviews and submit recommendations to client for determination
• Possess excellent analytical and critical thinking skills to assist in strategy as well as identifying appropriate utilization of additional clinical, vocational, or other resources
• Effective written and verbal communication skills to document clinical assessments reach out to Treating Providers engage in discussions with other resources including but not limited to Voluntary Benefit Claim Team Members, Clinical Peers and Vocational Rehabilitation Counselor Resources
• Data entry of contact into client systems and route as appropriate
• Exhibits ability to work independently with minimal supervision
• Utilize client specific criteria sets e.g.

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Qualifications

Basic Qualifications

• Current licensed Registered Nurse
• 2 years of acute care experience

Preferred Qualifications

• Prior insurance industry experience
• Experience with Voluntary Benefits, STD, or LTD products claims

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