Healthcare Specialist with Utilization Review Expertise

6 days ago

Étreux, Hauts-de-France, United States Wilmerhale Full time

Wilmerhale is a not-for-profit corporation that partners with public and private sectors to create high-quality, safe, and efficient delivery of healthcare and human services programs.

Estimated Salary: $120,000 - $150,000 per year

Job Summary:

This Senior Business Intelligence Engineer role performs high-level medical record and claims review for Medicare, Medicaid, or other claims data in order to ensure that proper guidelines have been followed. The successful candidate will act as a facilitator as well as a case manager regarding potential overpayment, fraud, waste, and abuse with regards to Medicare, Medicaid, and other medical claims.

Key Responsibilities:

  • Review Explanation of Benefit (EOB) cases, beneficiary, provider, and pharmacy cases for potential overpayment, fraud, waste, and abuse.
  • Completes desk review or field audits to meet applicable contract requirements and to identify evidence of potential overpayment or fraud.
  • Effectively identifies claims issues and determines root cause.
  • Interacts with beneficiaries, health plans, and medical service providers to obtain additional case-specific information, as needed.
  • Consults with Benefit Integrity experts for advice and clarification.
  • Completes inquiry letters, investigation finding letters, and case summaries.
  • Refers all potential fraud leads to the Investigators/Auditors.
  • Has basic understanding of the use of the computer for entry and research.
  • Responsible for case-specific or plan-specific data entry and reports.
  • Participates in internal and external focus groups and other projects, as required.
  • Identifies opportunities to improve processes and procedures.
  • Has the responsibility and authority to perform their job and provide customer satisfaction.
  • May participate as an audit/investigation team member for both desk and field audits/investigations.
  • Testifies at various legal proceedings as necessary.
  • Highly proficient in applying a large variety of more complex concepts, practices, and procedures within the field.
  • Relies on extensive experience and judgment to plan and accomplish goals.
  • Performs a variety of the more complex tasks requiring a wide degree of creativity and latitude.
  • May lead or direct the work of others, providing training and quality assurance for their work.
  • Provides job-specific orientation and training when called upon. With the Technical Trainer, the manager or others to develop training content, resources, and programs specific to job functions.
  • Documents records of training that include scheduling, registration, and attendance, quality control of training products, and evaluation summaries.

Supervisory Responsibilities:

The successful candidate may directly supervise employees. Carries out supervisory responsibilities in accordance with the organization's policies and applicable laws. Responsibilities include interviewing, hiring, and training employees; planning, assigning, and directing work; appraising performance; rewarding and disciplining employees; addressing complaints, and resolving problems.

Required Skills and Qualifications:

  • Analytical - Synthesizes complex or diverse information; Collects and researches data; Uses intuition and experience to complement data.
  • Problem Solving – Gathers and analyses information skillfully; Identifies and resolves problems.
  • Judgment - Supports and explains reasoning for decisions.
  • Quality Management - Looks for ways to improve and promote quality; Demonstrates accuracy and thoroughness.
  • Written Communication - Writes clearly and informatively; Able to read and interpret written information.
  • Professionalism - Approaches others in a tactful manner; Reacts well under pressure; Treats others with respect and consideration regardless of their status or position; Accepts responsibility for own actions; Follows through on commitments.
  • Managing People - Includes staff in planning, decision-making, facilitating, and process improvement; Takes responsibility for subordinates' activities; Makes self available to staff; Provides regular performance feedback; Develops subordinates' skills and encourages growth; Solicits and applies customer feedback (internal and external); Fosters quality focus in others; Improves processes, products, and services.; Continually works to improve supervisory skills.
  • Teamwork - Balances team and individual responsibilities; Exhibits objectivity and openness to others' views; Gives and welcomes feedback; Contributes to building a positive team spirit; Puts success of team above own interests; able to build morale and group commitments to goals and objectives; Supports everyone's efforts to succeed.

Education and/or Experience:

  • A BSN or RN with additional current and active degree/license/certification/s in a relevant healthcare discipline (i.e., CPC, CPHM, CCM, CFE, HCAFA).
  • Minimum five years clinical experience.
  • Healthcare experience that demonstrates expertise in conducting utilization reviews, ICD-9 coding, CPT coding, and knowledge of Medicare and/or Medicaid regulations preferred.
  • Prior successful experience with CMS, State Medicaid, and OIG/FBI or similar agencies preferred.

Certificates, Licenses, Registrations:

  • Current, active, and non-restricted RN licensure required.

Travel Requirements:

  • Depending on contract requirements, regular travel required, including overnight travel of up to 5 days per month which may require use of personal/rental vehicle for travel within the region.

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