Ideation Lead-Outpatient
Job Code : GEN/1185
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 and key responsibilities
This
role is initially to build and implement an effective Outpatient programs. 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:
·
Identify
new concepts which have the savings potential for development and deployment.
·
Drive
specific measurable results with timely deployment of concepts
·
Work
with audit leaders and establish a process to ensure the concepts being
deployed are working as expected with higher findings thus ensuring higher hit
rates and findings rates on the concepts deployed.
·
Ensure
to create review guidelines for concepts deployed to ensure operations and
audit staff have all the information they need to work the concepts.
·
Continually
identify and deploy new edits and algorithms to drive incremental savings
·
Establish
strong relationships with internal and external stakeholders to define, align
and delivery payment accuracy initiatives
·
Influence
leadership to adopt new ideas, and products as an experienced industry leader.
·
Develop analytics
around concepts provided by internal or external sources with assistance from
team members or direct supervision from development to production
·
Review data
requirements/design and implement logic to achieve data needs
·
Implement and develop
data concepts and monitor their impact
·
Serves as a resource
to operational claims and clinical staff, answering questions and assisting
with department informatics, reporting and trending, and workflow/operational
issues
·
Provide executive
level program updates and manage team escalations
· Comply with HIPAA Compliance and Security Policies and Procedures
·
Facilitate innovation
and continuous process improvement
Qualification
·
Bachelor?s
Degree ?
·
Active
CPC/COC certification
Required Skills and Experience:
·
5
years? experience in the health care industry (payer)
Experience in performing medical records
Review/ auditing claims
·
2 years?
experience in outpatient coding
·
Strong
Outpatient Surgery and Observation Coding/Auditing experience
·
Sound
knowledge of ICD-10-PCS/CM, CPT and HCPCs Coding Guidelines
·
Expertise
with Medicare LCDs and NCDs
·
Expertise
with NCCI Guidelines, OPPS, APC
·
Excellent
verbal and written communication skills
·
Experience
with encoder tools (3M, Webstrat, Optum, Truecode)
·
Maintains
working knowledge of CMS rules and regulations and knowledge of procedure and
diagnosis codes (CPT, ICD-9/10 coding, HCPCS and DRGs)
·
Should be
able to effectively coordinate with the development team and Stake Holders
Must be a team player and adaptable to a dynamic
work environment
·
Proficiency
in SQL/ PLSQL will be an added advantage
An ideal candidate should be:
·
Keep abreast
of industry trends and opportunities and apply best practice to payment
integrity and claims processing
·
Continually
identify and deploy new edits and algorithms to drive incremental savings
·
Ability to think analytically, apply analytical
techniques and to provide in-depth analysis and recommendations
to senior management using critical thinking and sound judgement
· Love collaborative environments that use agile methodologies to encourage creative design thinking and find innovative ways to develop with cutting edge technologies
· Proven interpersonal skills while contributing to team effort by accomplishing related results as needed
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!