JOB PURPOSE:Will be responsible for investigate claims / actions of potential healthcare fraud, waste & abuse activities (which includes onsite audit visits) and assist in educating & alerting the team members & stakeholders of possible FWA cases & trends by meeting or exceeding the set quality standard; delivering results in a timely and consistent manner, meeting all department quality and production goals and remaining current with all applicable business and audit processes.
JOB DESCRIPTION:
The specific duties in this role will include, but not limited to:
Conduct daily reviews & investigations on flagged potential fraud, waste, & abuse cases and take corrective measures.
Perform data analysis to detect spikes, trends, and abnormalities in provider behavior.
Develop new rules and hypothesis and enhance & optimize the existing rules & hypothesis to detect potential fraud, waste, and abuse and prevent future FWA.
Report daily production and findings in the respective tool.
Share findings of positive FWA cases with stakeholders to ensure prevention, avoidance or recovery.
Update Claims Team, Pre-Approvals and Network on new FWA trends and educate FWA handling to reduce unnecessary claims payment.
Review internal claims data/reports to analyze provider performance and thereby to detect and prevent incorrect coding, abuse and fraudulent billing practices to keep claims cost control.
Prepare claims samples and supporting documentation for the on-site review and to conduct on-site provider claims & quality audit to ensure proper coding & billing practices and compliance to contractual obligations.
Support the recovery process from the provider which is initiated based on the FWA investigation & Provider Audit findings.
Maintains, communicates, tracks, and trend audit results and report findings according to designated timelines.
Display detailed understanding of standard claim / review processes and work flows, providing consistency and appropriate detail in alignment with all policies & procedures, business rules, and overall departmental guidelines.
Extend support in reviewing internal reports to analyze provider performance, sampling, and provider on-site audit.
Maintain consistent and quality production standards with consideration around specific audit and turnaround expectations.
Collaborate, coordinate, and communicate across departments and stakeholders.
Ensure compliance with local regulatory requirements and regulations.
Demonstrate Company’s Core Competencies and values held within.
Key Responsibilities:
ROI & Customer Centricity: Support in performing Provider Audit to ensure medical necessity, detection of fraud, waste and abuse & ensure services billed were performed, correct utilization of CPT codes, etc. A savings target will be assigned for this role in line with the organizational roadmap.
Internal Partnership: Develop a feedback mechanism in coordination with Claims Manager to ensure adjudicators are aware of the FWA trends and educate them with FWA handling thus support in the development need of adjudicators and similarly developing a mechanism to provide feedback on providers behavior to Medical Network Team, Pre Approval Team and Case Management Team
P & L : Identification of risk, fraud, claims abuse via data analytics and information sharing with relevant teams to ensure such claims are controlled resulting in a positive impact on P & L. Similarly identification of cost effective methods for claims and pre approval for specific procedures
Strategy : Be responsible to support the TPA Audit process to drive results to identify trends for fraud, waste and abuse and to ensure operational efficiency & cost containment in the claims administrative process.
COMMUNICATIONS & WORKING RELATIONSHIPS:
Internal: Claims Manager, Medical Network & Relationship Manager, Enabling Function Manager, EB Sales Managers, and Medical Liaison Manager
External: Healthcare Providers, Policyholders, regulatory authorities.
QUALIFICATIONS, EXPERIENCE, & SKILLS:
Bachelor’s degree preferably in medical related field or equivalent combination of education and applicable work experience.
Coding certification from a relevant association (AAPC, AHIMA etc) recognized by local regulatory authorities (DHA, DoH etc); preferably as a certified medical auditor.
2 – 3 years of experience with provider & payer to have a strong knowledge of billing patterns and coding
Strong record of success in data analytics and identification of fraud patterns from providers
Possess skills to develop creative solutions for medical quality management
Possess skills for feedback mechanism for different stakeholders
Strong understanding of medical terminologies (diagnosis, services etc) is required.
In depth knowledge and understanding of insurance terminologies, medical policy terms and conditions stipulated in policy contracts.
A graduate degree, MBA degree or other advance degree is preferred.
A nursing degree or Pharmaceutical or Medical degree will be of value however not mandatory.