Position background: This role requires coding knowledge, but mostly serves as fulfilling an auditor-type role. Recovery/Resolution Analysts are ensuring that provider billing practices meet expected state, federal, and CMS guidelines.
What does this position accomplish for the business? This job involves investigating claims that are stopped prior to payment. The intent is to prevent any instances of fraud, waste, or abuse upon provider billing.
Please describe the team the candidate will be working with (number of team members break-down of the team's skill sets team culture etc.). Teams consist generally of 10-20 employees. All employees are remote/telecommuting in nature. Everyone will be completing the same analyst type function. There will be a Manager and Team Lead provided for support.
What are the top 5-10 responsibilities for this position (Please be detailed as to what the candidate is expected to do or complete on a daily basis)?
- Will review Clinical Case reviews for potential fraud, waste, or abuse approximately 75% of their day
- Will review clinical professional (or facility) claims, as well as associative medical records to determine if the claim billing procedures are supported or unsupported.
- Will maintain standards for productivity and accuracy. Standards are defined by the department.
- Will provide clear and concise clinical logic communication to the providers when necessary.
- Will engage with internal business partners by either seeking or providing support from time to time.
- Will attend and provide feedback during various weekly/monthly team meetings.
- Will be solicited for providing feedback on how to improve department relationships or processes with internal team members and departments.
- Will be asked to keep up with any required Coding Certification and/or Nursing Licensure.
- Will be asked to complete mandatory coursework as required by the department.
Benefit packages for this role will start on the 31st day of employment and include medical, dental, and vision insurance, as well as HSA, FSA, and DCFSA account options, and 401k retirement account access with employer matching. Employees in this role are also entitled to paid sick leave and/or other paid time off as provided by applicable law.