Healthcare Appeals and Grievance Analyst

Health Admin Services Analyst

Skill required: Claims Appeals - Claims Administration
Designation: Health Admin Services Analyst
Qualifications:BBA/BCom/BMS
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 – Appeals & Grievance (A&G) serves as a functional expert responsible for providing guidance on complex cases, ensuring regulatory compliance, and supporting process improvements. This role acts as a bridge between operations, quality, and leadership by offering expertise in appeals and grievance handling, resolving escalations, and enhancing team performance. Subject Matter Expertise: Act 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 guidelines and business rules Case Review & Resolution: Review and validate high-risk, sensitive, or complex cases Ensure proper documentation, investigation, and resolution of appeals and grievances Support root cause analysis for recurring issues Compliance & Quality Assurance: Ensure adherence to regulations from the Centers for Medicare & Medicaid Services (CMS) and internal policies Maintain compliance with Health Insurance Portability and Accountability Act (HIPAA) for data security and confidentiality Conduct quality audits and provide detailed feedback to improve accuracy Assist in preparing for internal and external audits Training & Knowledge Sharing: Train new hires and provide ongoing training to team members Develop and update standard operating procedures (SOPs) and training materials Share updates on policy changes, regulatory updates, and process improvements Stakeholder Support: Collaborate with cross-functional teams (claims, enrollment, billing, providers) Act as escalation support for team leads and managers Communicate effectively with internal and external stakeholders regarding case status and resolutions Process Improvement & Reporting: Identify process gaps and recommend improvements Analyze trends in appeals and grievances to reduce errors and complaints Support reporting on quality metrics, compliance, and operational performance
What are we looking for? Strong expertise in appeals and grievance processes In-depth knowledge of healthcare regulations and compliance Excellent analytical and problem-solving skills Strong communication and training abilities Attention to detail and decision-making capability Ability to handle complex and sensitive cases
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 require you to work in US Shift time. No morning or rotational shifts