Offer summary

Qualifications:

5+ years of experience in direct claim processing and reimbursement., 3+ years of management experience in claims processing is preferred., Strong knowledge of auditing rules and methodologies in healthcare., Excellent communication and interpersonal skills are essential..

Key responsibilities:

Lead a team in identifying audit opportunities and improving payment integrity processes.

Analyze payment-related data to ensure compliance and prevent fraud.

Participate in client meetings and communicate claims payment practices effectively.

Manage team training and development while contributing to data mining programs.

Job description

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.

Job title:

Data Mining Consultant (Client Lead)

Job Description:

We are currently hiring a talented Consultant II, Lead Consultant Data Supervisor. This is a client facing role responsible for leading a team of experienced professionals in identifying new audit opportunities, researching pricing methodologies, and engaging with various work teams to generate systems automation and enhancement capabilities in our state-of-the-art audit workstation. In this role you will develop, train, and manage a team of dedicated professionals to ensure client targets and KRA's are met while also acting as an individual contributor in these areas.

Key Requirements:

Review and analyze payment-related data using data mining techniques to ensure accuracy, compliance, and fraud prevention in financial transactions.
Lead team members to meet targets.
Ideate and perform audits on payment data, identifying discrepancies, errors, and fraudulent activities, and providing recommendations for process improvement.
Manage the supervision, training, and development of their team as well as the data collection, data analytics and data reporting for data mining programs including but not limited to COB, Duplicate, Contractual, billing errors, and overlapping services.
Participate in client meetings and lead pertinent discussions.
Communicate client claims payment practices and ensure information shared with their team.

Education, Experience, and Skills:

5+ year’s knowledge of direct claim processing/reimbursement, medical facility contracts, fee schedules, inpatient/outpatient/physician claims required.
3 or more years of management experience in claims processing is a strong plus.
Experience Ideating & developing new auditing rules and paradigms.
Experience in business case analysis and help designing BRD, pricing, COB, platform analytics.
Experience of Validation of Rules through testing methodologies, auditing, payment processing, or financial fraud prevention is a must.
Load and synthesize healthcare data from multiple sources.
Experience working within a health plan, managed care organization, provider operated healthcare environment or third-party administrator.
Development of end-to-end payment Integrity reports like Data Intake, Audit Selections, Findings, Appeals, Medical record Management, Audit Operations, Recovery Operations, Provider Correspondence and Forecasting & Invoicing.
Maintaining a working knowledge of CMS transmittals, RAC, and OIG reports is a must.
Prior claims auditing or consulting experience desirable in either a provider or payer environment.
Provide recommendations for improving payment integrity processes, fraud prevention measures, and operational efficiency based on audit findings.
Work with audit teams 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.
Excellent communication skills both oral and written.
Strong interpersonal skills that will support collaborative teamwork.
Microsoft Office Proficient: Word and Excel; Access – highly preferred
Ability to interpret and assess complex payment datasets.
Excellent communication and interpersonal skills.