About Sagility LLC

Sagility LLC - 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.

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.

Job Role

This position is responsible for review or audit medical records for completeness and accuracy by looking at various pieces of documentation. This includes post and pre-pay audit functions, payment recovery processes and medical record review.

Additional responsibilities include identifying and building concepts by reviewing CMS guidelines, policies and client specific criteria.

Key Responsibilities:

• 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

Qualifications

·         Bachelor?s degree in Nursing and Midwifery/General Nursing and Midwifery

·         Active NCLEX-RN license ? Mandatory

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Preferred Skills and Experience:

·         Experience in performing medical records Review/ auditing claims -Preferred.

·         Certified Skilled Nursing Nurse with MDS and RUG / PDPM knowledge of the guidelines, reimbursements, Ideation and new concept development skill to identify overpayments. 

·         2 years of experience in auditing 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   

·         Proficiency in written and verbal communication

·         Proficiency in medical record Review-Preferred

·         Should be able to effectively coordinate with the internal team and Stake Holders

An ideal candidate should be:

·         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

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