Sagility is a strategic business process management provider of transformative Healthcare solutions that help our clients significantly enhance the Member and Provider experience while providing for operational excellence to optimize the back office.

If you seek an opportunity to work with top clients around the world and be part of an enriching and nurturing work environment, check out this career opportunity with the Sagility Team!

We are currently hiring a talented Ideation Lead for our Payment Integrity Team.  In this role you will create and implement an effective Skilled Nursing Facility audit program using program framework to develop rules to identify the claims for audit, create review guidelines and train the audit teams.  The Ideation Lead also identifies and builds concepts by reviewing CMS guidelines, policies, and client specific criteria. 

• Set up and create the SNF audit program using program framework to develop rules to identify the claims for audit
• Create review guidelines
• Train effective audit teams
• Identify and build concepts by reviewing CMS guidelines, policies, and client specific criteria
• Facilitate innovation and continuous process improvement 
• Review the medical records by applying appropriate medical review guidelines, policies and rules
• Leverage the Sagility integrated payment integrity technology platform to identify and understand the tasks involved related to client implementations
• Document all findings referencing the appropriate policies and rules
• Support findings during the appeals process if requested 
• Work in partnership with clients, and other contractors to improve medical policies, provider education, and system edits
• Audit claims for medically appropriate services provided in both inpatient and outpatient settings
• Observe trends in medical records to develop concepts for future audits
• Comply with HIPAA Compliance and Security Policies and Procedure 

• Bachelor of Science in Nursing (BSN)
• Active RN License Required
• Certified Skilled Nursing Nurse with MDS Certification

Required Skills and Experience: 

• Minimum 5 years experience working for a healthcare vendor or payer auditing SNF claims
• RUG / PDPM knowledge- guidelines, reimbursements, Ideation, and new concept development skill to identify overpayments  
• Experience in performing medical records review/ auditing claims  
• 2 years of experience in skilled nursing facility claims
• 2 years of clinical nursing experience in the inpatient setting. 
• Experience in the health care industry (Medicare, Medicaid, and/or Commercial) 
• Advanced proficiency in MS word, Excel, and PowerPoint ?? 
• Ability to learn and become proficient using an integrated payment integrity technology platform
• Proficiency in written and verbal communication 
• Effectively coordinate with the internal team and stake holders
• Ability to work independently and as a team
• Keep up to date on industry trends and opportunities to apply best practices 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
• Strong written and verbal communication skills
• Good analytical, decision making and problem-solving skills
• Strong clinical knowledge and effective use of multiple applications, systems, and resources

Sagility offers competitive benefits including:

• Medical
• Dental
• Vision
• Life Insurance
• Short-Term and Long-Term Disability
• Flexible Spending Account
• Life Assistance Program
• 401K with employer contribution
• PTO and Sick Time
• Tuition Reimbursement

Join our team, we look forward to talking with you!

Sagility is proud to be equal opportunity employer. We celebrate diversity and are committed to creating an inclusive environment for all employees.