Ideation Lead - Skilled Nursing
Job Code : GEN/1132
Work@HomeJob Description
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 role is initially to
build and implement an effective Payment Integrity Skilled Nursing Facility Payment Integrity department.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
·
Qualifications
·
Bachelor?s degree
in Nursing and Midwifery/General Nursing and Midwifery
· Active NCLEX-RN license
·
Experience in performing medical
records Review/ auditing claims
·
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
·
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