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For your reference, we have included the original job posting below.
SIU Pre Payment Review Specialist
Job Number:
43831618
Company Name:
Universal American Corporation
Job Location:
Houston, TX US
Job Category:
Healthcare & Medical
SIU Pre Payment Review Specialist
SIU Pre Payment Review Specialist Tracking Code 305288-763 Job Description
This position is responsible for reviewing suspect claims prior to payment that have been identified as suspicious and/or potentially fraudulent. Utilizing a combination of Company designated tools and healthcare claims expertise, the individual is expected to review and determine the appropriateness of the pending claim payment, and if warranted, make a determination for denial or other proposed action. Responsibilities: * Perform intensive claims reviews on pended claims that have been identified as suspicious and/or potentially fraudulent, utilizing most current reference materials to include, but not limited to: Current Procedural Terminology (CPT), Internal Classification of Disease-9thEdition (ICD-9), Prospective Payment System-Resource Utilization Groups (PPS-RUG), Diagnosis Related Grouper (DRG) and Healthcare Common Procedure Coding System (HCPCS) guidelines * Document decisions on denied claims with thorough notation, and be prepared to discuss these decisions with provider, vendor or designated billing personnel as required to educate and correct billing issues * Receive and scan incoming FWA appeals, reevaluate previous claim decisions based on provided documentation and research, coordinate with Company personnel as required in making final determination and inform provider of decision * Coordinate with FWA team members to continually provide updates on newly identified billing/coding trends, suspicious providers, gaps in clinical policy, provider contract issues, system configuration and pricing errors, claim processor errors via manual adjustment and provide leads on potential post-payment investigations * Familiar with Centers for Medicare and Medicaid Services (CMS) payment policies, Local Coverage determinations (LCDs), National Coverage Determinations (NCDs), Correct Coding Initiatives (CCI) Edits, Company clinical policy, Company benefit programs and other coverage determinations to include documenting and maintaining such policies for both SIU and Company reference. * Create reports using the Company designated pre-payment tool to identify potential fraud trends, perform analysis of those trends, and provide risk mitigation recommendations (e.g. new trends and fraudulent schemes, spikes in fraudulent activity). * Monitor and participate with NHCAA membership sharing and collecting data to recognize national trends or schemes to proactively anticipate threats. * Monitor and participate in AAPC Forum discussions and disseminate knowledge and updates through the organization Required Skills
* Strong oral communication skills * Must have strong organizational/time management skills * Collaborative team player * Attended a course in medical billing * Proficiency with Company designated PC Office tools * Knowledge of CMS 1500 and UB04 data elements * Strong knowledge of standard industry coding guides such as CPT, HCPCS, ICD-9, and Revenue Codes * Basic analytical and problem solving skills * Ability to support heavy workload volume and meet critical regulatory guidelines. * Collaborative team player * Effectively manages time and works independently needing little or no supervision Required Experience
* Experience in anti-FWA activities to include SIU or Program Integrity Units/Programs * Previous pre-payment experience to include determinations and appeals * Experience in Medicare or Medicare Advantage Private Fee For Service (PFFS), Health Maintenance Organization (HMO) and Preferred Provider Organization (PPO) claims processing * Must have a good level of working knowledge of medical coding (i.e. CPT, ICD-9, HCPCS, Revenue, etc.) Education * High School Diploma required * Completed a medical coding course * Member of AAPC preferred Universal American Corp. is proud to be an equal opportunity/affirmative action employer. We are committed to attracting, retaining and maximizing the performance of a diverse and inclusive workforce. Job Location Houston, TX, US. Position Type Full-Time/Regular
