Careers At Sagility

Ideation Lead – HCD/DME– Payment Integrity

Job Code : GEN/1184

Job Description

About Sagility

Sagility is a tech-enabled BPM services provider, a thought partner providing a broad spectrum of transformational services, to enable our clients provide efficient and hi-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 2022 as a part The Healthcare Payer Operations PEAK Matrix Assessment report by Everest Group. To learn more about our recognitions please visit our AWARDS SECTION

We have 28,000 employees in 15 cities across 5 countries ? India, Philippines, USA, Jamaica, and Colombia.

Job role

This role is to build and implement an effective HCD/DME audit program. This position is responsible for setting up the audit program using program framework to develop rules to identify the claims 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. 

Key Responsibilities    

Developing proprietary Datamining and clinical rules for identifying the Overpayments in High Cost Drugs (HCD) and Durable Medical Equipment(DME) 

         Perform ongoing research of CMS and Payer policies and pricing to ensure concepts are current and relevant.  

         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.  

         Develop audit review guidelines using ICD-10 CM, PCS Coding guidelines, AHA coding clinics, UHDDS guidelines, Medicare/Medicare rules.  

         Updating and developing new HCD/DME 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    

        Familiarity with SQL/PLSQL will be an added advantage 


? B-Pharm graduation 

Required Skills and Experience:  

? 3 -5 Years? US healthcare payer experience in HCD/DME Coding/ Clinical Validation/ HCD/DME Quality Auditor 

? 2 Year in ideation& research and new concept development in HCD/DME 

? Experience in performing medical records Review/ auditing claims 

An ideal candidate should be also:  

         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


Your life with us 

Sagility believes in Doing Right by its People.  We believe in providing strong growth opportunities, multiple training programs to support your learning curve, exposure to large international clients and access to advanced technologies and solutions at your disposal - so that you can focus on making a difference through your role.  

We are an inclusive, open, and welcoming organization where our people are at the heart of everything that we do. We believe in giving back to the local communities in which we operate. We have strong rewards and recognition platforms, programs where your ideas can turn into reality 

We respect the need for a composite life and to encourage the same, we have employee friendly leave policies for the much needed down time and a lot more. Our medical insurance coverage is one of the best in class, covering you and your family when you need it. Last but not the least, we have lots of fun everyday through our wellbeing programs, talent shows, engagement activities - it?s an endless list! 

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