Sagility combines industry-leading technology and transformation-driven BPM services with decades of healthcare domain expertise to help clients draw closer to their members. The company optimizes the entire member/patient experience through service offerings for clinical, case management, member engagement, provider solutions, payment integrity, claims cost containment, and analytics. Sagility has more than 25,000 employees across 5 countries.

This role is initially to build and implement an effective DRG 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

Job title:

Consultant II Ideation & Analytics DRG

Job Description:

Education:

Bachelor’s degree in Science /Pharmacy/Nursing

Experience:

5+ years’ experience in the health care industry (Payer)
3+ Years’ experience in DRG Coding/ Clinical Validation/DRG Quality Auditor
1+ Year in research and Ideation for Clinical Audit Programs

Mandatory Skills:

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

Preferred Skills:

Proficiency in MS word, Excel and PowerPoint

Roles & Responsibilities:

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 analyse medical claim data to discover incorrect claims.
Development of ICD-10 CM, PCS Coding guidelines, AHA coding clinics, UHDDS guidelines, Medicare/Medicare rules.
Updating and developing new DRG 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

Location:

Work@Home USAUnited States of America

Originally posted on Himalayas