AM/Manager - Workers Compensation Audit - US Healthcare Payer Claims

Role Overview:

- Good understanding of US Healthcare Payer Claims

- Experience in audit of workers compensation medical bills

- Strong understanding of CMS & State payment policies

- Expert in State Fee Schedules and payment hierarchy

- Good analytical and communication skills

Responsibilities:

- Serve as subject matter expert and analyze claims payments as per state workers compensation guidelines

- Quality audit of workers compensation medical bill payments

- Responsible for the accurate and thorough investigation of potential fraud and abuse involving workers compensation

- Provide ideas to technical team of potential overpayment cases

- Documentation of provider communication

- Proactively gather feedback from users

- Quick turnaround using logical understanding of data

- Tracking and reporting of assigned tasks for internal and external stakeholders

Candidate Profile:

- Candidates with 7+ years of US healthcare claims experience

- Experience in audit of workers compensation medical bills payment

- Knowledge of CPT, Modifiers, ICD-10, DRG, Revenue codes and preauthorization guidelines

- Comprehensive knowledge on health care industry, medical bills processing, AR and payment posting cycle

- 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