Ideation Lead - Home Health
Job Code : GEN/1129Work@Home
About Sagility LLC
Sagility is a tech-enabled BPM servives provider, a thought partner providing a broad spectrum of transformational services, to enable our clients to provide efficient and high quality care across the healthcare system.
Sagility combines industry-leading technology and transformation-driven BPM services with decades of healthcare domain expertise to help clients draw closer to their members. We optimize the entire member/patient experience through service offerings for clinical, case management, member engagement, provider solutions payment integrity, claims cost containment, and analytics.
Leading industry analyst firms have consistently cited our service excellence, breadth of offerings, and ability to execute. The most recent being recognized as a leader for Healthcare Payer Operations in 2011 as a part of the Healthcare Payer Operations PEAK Matrix Assessment report by Everest Group. To learn more about our recogniztions please visist our Awards Section.
We have 28,000 employees in 15 cities across 15 countries - India, Philippines, USA, Jamaica, and Colombia.
About the Department
Payment Integrity is the service offering of Sagility LLC, we work closely with Healthcare Operations to provide services including Development, Analytics & Reporting and Data Science Modeling to healthcare customers.
This role is initially to build and implement an effective Home health audit program. This position is responsible for setting up the audit program using program framework to develop rules to identify the claim for audit, create review guidelines and train the audit teams. Additional responsibilities include identifying and building concepts by reviewing CMS guidelines, policies and client specific criteria.
- Reviewing the medical record by applying appropriate medical review guidelines, policies and rules.
- Documenting all findings referencing the appropriate policies and rules.
- Supporting your findings during the appeals process if requested.
- Work in partnership with our clients, and other contractors on improving medical policies, provider education, and system edits.
- Auditing claims for medically appropriate services provided in both inpatient and outpatient settings.
- Identify new methods/ideas to improve productivity and quality and to improve client savings.
- Observe trends in medical record to develop concepts for future audits.
- Comply with HIPAA Compliance and Security Policies and Procedures
- Facilitate innovation and continuous process improvement
- Bachelor?s degree in Nursing and Midwifery/General Nursing and Midwifery
Active NCLEX-RN license
- 5 years of experience in the healthcare industry(Payer)
- Experience in performing medical records review/auditing claims
- Certified Home Health Nurse ( COS-C or HCS-O)
- 2 years of experience in home health care claims that demonstrates knowledge in ICD-9/ICD-10 coding, HCPS/HIPPS coding
- Experience in the health care industry (Medicare,
Medicaid, and/or Commercial)
- Advanced proficiency in MS word, Excel and PowerPoint
- Proficiency in written and verbal communication
- Should be able to effectively coordinate with the internal
team and Stake Holders.
- Ability to work independently and as a team.
- Ability to work within the turnaround times.
- Keep abreast of industry trends and opportunities and apply best practice to payment integrity and claims processing.
- Ability to think analytically, apply analytical techniques and to provide in-depth analysis and recommendations to senior management using critical thinking and sound judgement.
- Must be a team player and adaptable to a dynamic work environment.
- Proven interpersonal skills while contributing to team effort by accomplishing related results as needed.
- Strong written and verbal communication skills.
- Good analytical skills, Decision making, comprehensive thinking and Problem solving skills.
- Good clinical knowledge and effective use of multiple applications, systems and resources.
- Must ensure to meet productivity and quality targets and update/maintain the required reports
- Continuous professional development
- Diverse and inclusive work culture
- Be empowered to make a difference
- We focus on people on a break
- Be recognized and rewarded