Ideation Lead – HCD/DME– Payment Integrity
Job Code : GEN/1184
Work@HomeJob 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
Qualification:
? 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!