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 SNF 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 Skilled Nursing Job Description: Education: Bachelor’s degree in Nursing and Midwifery/General Nursing and Midwifery Experience: 5+ years’ experience in the health care industry (payer) Experience in performing medical records Review/ auditing claims -Preferred. 2+ years of experience in auditing skilled nursing facility claims. 2+ years of clinical nursing experience in the inpatient setting. 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: Advanced proficiency in MS word, Excel and PowerPoint Proficiency in written and verbal communication Proficiency in medical record Review-Preferred Should be able to effectively coordinate with the internal team and Stake Holders Roles & Responsibilities: Key Responsibilities: Reviewing the medical record by applying appropriate medical review guidelines, policies and rules. Documenting all findings referencing the appropriate policies and rules. Supporting your findings during the appeals process if requested. Work in partnership with our clients, and other contractors on improving medical policies, provider education, and system edits. Auditing claims for medically appropriate services provided in both inpatient and outpatient settings. Identify new methods/ideas to improve productivity and quality and to improve client savings. Observe trends in medical record to develop concepts for future audits. Comply with HIPAA Compliance and Security Policies and Procedures Facilitate innovation and continuous process improvement The above statements are intended to indicate the general nature and level of work being performed by employees within this classification. They are not intended to be an exhaustive list of all responsibilities, duties and skills required of employees assigned to this job. Employees in this job may perform other duties as assigned Location: Work@Home USAUnited States of America 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.
