Careers At Sagility

Ideation Lead - DRG

Job Code : GEN/1131
Work@Home

Job Description

About Sagility LLC

Sagility LLC, formerly HGS Healthcare - a global leader in business process management, specializes in augmenting healthcare teams to deliver better patient, member, business and financial outcomes. Factoring the needs of health plans and providers, we interact with members and patients to deliver evidenced-based, timely, preventative, personalized, cost-effective and whole-person care that improves health, value and quality of life.

We help our clients help others by assuming responsibility for non-core activities, such as claims processing, clinical appeals, member administration, customer service, provider management, data management and analytics, collections, compliance and adherence, and back-office administration.

 

Job Role

This process works on identifying Fraud, Waste and Abuse between medical records and billed services for complex and high value claims by identifying correct coding and misrepresentation of services. The associates prevent the payment of potentially fraudulent and/or abusive claims utilizing medical expertise, knowledge of CPT/ diagnosis codes, CMS guideline along with referring to client specific guidelines and member policies.

 

 

Key Responsibilities:

  • Prevent the payment of potentially fraudulent and/or abusive claims utilizing medical expertise, knowledge of CPT/diagnosis codes, CMS guideline along with referring to client specific guidelines and member policies

         Identify, Interpret, develop, and implement new concepts that will recognize incorrect payments. Concepts are developed based on industry experience, regulatory research, and ability to analyze medical claim data to discover incorrect claims.

         Owning medical policies end to end.

         Development of ICD-10 CM, PCS Coding guidelines, AHA coding clinics, UHDDS guidelines, Medicare/Medicare rules.

         Updating and developing new DRG and current audit recovery reports, developing and running custom queries.

         Researching reimbursement regulations for claim payment compliance reviews and documentation to support current audit findings

 

 

Qualifications

  • 3 Years? experience in DRG Coding/ Clinical Validation/DRG Quality Auditor
  • 1 Year in research and Ideation for Clinical Audit Programs

 

 

 

An ideal candidate should be:

         Proficient in working with high availability environment along with alignment to process

         Love collaborative environments that use agile methodologies to encourage creative design thinking and find innovative ways to develop with cutting edge technologies

         Ambitious individual who can work under own direction towards agreed targets/goals and with creative approach to work

         Intuitive with an ability to manage change and proven time management

         Proven interpersonal skills while contributing to team effort by accomplishing related results as needed

         Up-to-date in technical knowledge by attending educational workshops, reviewing publications

 

Our promise

          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

 


Apply For This Job Back