Manager/ Senior Manager

  • Noida
  • Confidential
  • 10-15 years
  • Views
  • 23 Apr 2018

  • Audit and Assurance

  • Consumer Durables/ Semi Durables
Job Description

Manager/Senior Manager - DRG Audit - Medical Coding - US Healthcare Payer Claims (10-15 yrs) Role Overview: - Good understanding of US Healthcare Payer Claims & Medical coding - Expert in auditing of hospital Inpatient claims - Strong understanding of CMS payment policies and provider contracts - Proficient in healthcare reimbursement methodologies - Good analytical and communication skills Responsibilities: - Serve as subject matter expert and analyze claims payments as per Payer and CMS payment guidelines - Conduct Inpatient DRG and APC coding quality checks - Maintain knowledge of coding and billing requirements and regulatory changes - Responsible for the accurate and thorough clinical investigation of potential fraud and abuse involving commercial and government lines of business - Provide ideas to technical team of potential overpayment cases - Ability to effectively interface with all levels of coding and auditing personnel (internal / external) and customers - Quality check of claims adjudication and payments - Work with analytics team to identify and automate repetitive tasks - Quick turnaround using logical understanding of data - Tracking and reporting of assigned tasks for internal and external stakeholders Candidate Profile: - 10+ years of experience in pre-payment and post-payment audit of US Healthcare Claims - Must be CCS / CPC certified - Must have worked on facility coding operations (IP DRG, ED, ER, SDS) - Comprehensive knowledge on US health care industry, Institutional and Professional Claims - Subject matter expert and analyze medical billing as per Payer, State and CMS guidelines - In-depth technical knowledge of ICD-9-CM, ICD-10-CM, CPT & Revenue Codes coding conventions, AP-DRG, APR-DRG, MS-DRG and APC assignment, Present on admission guidelines, secondary diagnoses classification for MCCs/CCs, MDCs, E/M leveling, Medical terminology and anatomy and physiology - Expertise in complex clinical coding/reviewing assignments, difficult investigations and highly visible issues - Excellent knowledge of utilization management and preauthorization guidelines - Thorough knowledge of payment rules hierarchy, fee schedule configuration and their impact on payment - Capability to provide inputs to technical team with potential cases of overpayment in Institutional and Professional medical bills - Preferred experience in data mining techniques using SAS/SQL/R or other similar language - Superior skills to effectively communicate and negotiate across the business and external health care environment - Demonstrate ability to interact effectively with non-technical clients and internal teams - Must be a dependable and reliable player, able to work independently and as part of a goal oriented team with a positive attitude - Must have strong analytical, reasoning, organizational and management skills

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