Responsible for researching and investigating complex medical cases for the purpose of detecting fraud and abuse, both internal and external, involving submission/payment of claims.
Primary Job Duties:
- Performs risk analysis to determine Providers, areas of concern and issues to be audited.
- Manages, prioritizes and directs workflow/activities for the Reimbursement Integrity Unit. Ensures that staff is fully aware of department and organizational goals and objectives and that all audit activities are properly defined and documented.
- Responsible for hiring, training and evaluation of staff.
- Assists director in the development and implementation of the RIU Annual Business Plan.
- Develops and monitors annual budget for RIU/SIU Departments, ensuring that all projects/audits/investigations are completed within the timeframe and budget allotted.
- Responsible for the development and coordination of processes and initiatives that support the RIU function across all departments, commercial divisions and facilities. Coordinates audit activities performed by external audit entities as well as with HealthNow's internal personnel.
- Monitors the completion of various functions including retroactive adjustments to providers and recovery of payments to providers to accurately reflect proper reimbursement for services. This includes the coordination of audit activity efforts with providers and internal departments including Special Investigations, Informatics, Network Management, Utilization Management and Pharmacy Benefits.
- Resolves issues/conflicts between the intent of provider contracts and the contracts relative to reimbursement policies. This includes meeting with internal departments (Network Management/Utilization Management) as well as providers to provide: Education and training; Negotiation of settlement terms; Execution of adjustments and negative balance transaction as required.
- Defines project goals and objectives and develops project plans in a manner consistent with accepted professional standards to ascertain the extent of compliance with policies, procedures, laws and regulations. Ensures that project meets goals and within budget and timeframe.
- Coordinates activities with outside subcontracted audit firms to include the following: Identify potential problems; Make data available to vendors; Consolidate data; Track contract performance; Track and analyze audit results; Ensure quality in contracted audit process; Contractor settlement process.
Bachelors Degree (N/A)
- Strong analytical skills, ability to interpret contract reimbursement schedules and policies
- Ability to work independently to achieve recovery goals
- Ability to prioritize workload and take initiative
- Work within and support a team environment
- Strong interpersonal communication skills, including ability to make decisions
- Ability to deal with professionals both internally and externally
- Personal Computer (PC) and superior written, verbal and interpersonal skills are required
- Demonstrated competency in defining problems, collecting information to solve them, recommending effective solutions and handling multiple tasks independently are required
- Strong management and leadership skills, training, coach and develop staff
Or the equivalent experience in healthcare provider claims, medical billing or Correct Coding Initiative Guidelines (CCI). Minimum of 3 years of provider relations and/or provider audit experience in a healthcare organization desired.
No degree specified (N/A)
Registered Professional Nurse, Certified Professional Coder (CPC), Certified Professional Coder ? Hospital (CPC-H), Certified Coding Specialist (CCS), OR Registered Health Information Administrator/Technician (RHIA/RHIT) certification required.
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