Description

The payment integrity team uses algorithms and best practices to capture provider and claim outliers, and recovery opportunities related to FWA (Fraud, Waste, and Abuse). Specifically, WM is required to investigate situations of potential fraud, waste and abuse. The purpose of our Fraud, Waste and Abuse (FWA) program is to protect the ethical and fiscal integrity of our health care benefit plans and programs. Our program main functions are to: Ensure reimbursement accuracy. Keep up to date on new and emerging FWA (Fraud, Waste and Abuse) schemes. Discover methodologies and technologies to combat FWA. Job Description: Regular review of claims data to identify areas of high utilization, provider outliers, new code abuse, upcoding, modifier usage, etc. Clinical Claims Reviews Assist Claims in the review of medical records submitted to request payment related to specific modifiers (e.g., 22, 62 Review of medical records may lead to discovery of a provider that is billing inappropriately. Pre-Payment review via payment integrity pend codes. Post payment review. Medical record review of clinical/coding documentation. Minimum Qualifications: Bachelors degree preferably life science background. Medical coders with 2 to 4 years of experience in multispecialty coding (ED/E&M along with Radiology, Pathology or Surgery). AAPC/AHIMA certification is a mandate requirement. CPC/COC/CIC/CPMA/CDEO/CHC/CCS Coders working in Payment Integrity / Adjudication process will be given first preference. Must understand trend information and be familiar with claim coding practices and industry issues in Medicare payment methodologies. Professional Competencies: Excellent communication skills, both written and verbal. Integrity and Trust. Customer Focus. Moderate level experience with Excel and other data systems.

Role and Responsibilities

• The payment integrity team uses algorithms and best practices to capture provider and claim outliers, and recovery opportunities related to FWA (Fraud, Waste, and Abuse). Specifically, WM is required to investigate situations of potential fraud, waste and abuse. The purpose of our Fraud, Waste and Abuse (FWA) program is to protect the ethical and fiscal integrity of our health care benefit plans and programs. Our program main functions are to: Ensure reimbursement accuracy. Keep up to date on new and emerging FWA (Fraud, Waste and Abuse) schemes. Discover methodologies and technologies to combat FWA. Job Description: Regular review of claims data to identify areas of high utilization, provider outliers, new code abuse, upcoding, modifier usage, etc. Clinical Claims Reviews Assist Claims in the review of medical records submitted to request payment related to specific modifiers (e.g., 22, 62 Review of medical records may lead to discovery of a provider that is billing inappropriately. Pre-Payment review via payment integrity pend codes. Post payment review. Medical record review of clinical/coding documentation. Minimum Qualifications: Bachelors degree preferably life science background. Medical coders with 2 to 4 years of experience in multispecialty coding (ED/E&M along with Radiology, Pathology or Surgery). AAPC/AHIMA certification is a mandate requirement. CPC/COC/CIC/CPMA/CDEO/CHC/CCS Coders working in Payment Integrity / Adjudication process will be given first preference. Must understand trend information and be familiar with claim coding practices and industry issues in Medicare payment methodologies. Professional Competencies: Excellent communication skills, both written and verbal. Integrity and Trust. Customer Focus. Moderate level experience with Excel and other data systems.