Business Development Manager Litigation

4 weeks ago

Palo Alto, California, United States Wilmerhale Full time
Job Summary

This is a contingent hire mid-level professional position that will perform medical record and claims review for Medicare, Medicaid, and/or other claims data in order to ensure that proper guidelines have been followed.

Key Responsibilities
  • Review Explanation of Benefit (EOB) cases, beneficiary, provider, and/or pharmacy cases for drug seeking, drug selling, beneficiary and other 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 and resolves claims issues and determines root cause.
  • Interacts with beneficiaries and health plans to obtain additional case specific information, as needed.
  • Consults with Benefit Integrity investigation experts and pharmacists for advice and clarification.
  • Completes inquiry letters, investigation finding letters, and case summaries.
  • Investigates and 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 reporting.
  • 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
  • Has developed expertise with standard concepts, practice and procedures in field. Relies on limited experience and judgment to plan and accomplish goals.
  • Testifies at various legal proceedings as necessary.
  • May mentor and provide guidance to junior and level one analysts.
  • Performs a variety of tasks some requiring independent thought and research. A degree of creativity and latitude is required.
Requirements
  • 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.
  • Written Communication - Writes clearly and informatively; Able to read and interpret written information.
  • Quality Management - Looks for ways to improve and promote quality; Demonstrates accuracy and thoroughness.
  • Interpersonal Skills - Focuses on solving conflict, not blaming; Maintains confidentiality; Listens to others without interrupting; Keeps emotions under control; Remains open to others' ideas and tries new things.
  • 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.
  • 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.
Education and Experience
  • BSN OR an RN with additional current and active degree/license/certification/s in a relevant healthcare discipline (i.e., CPC, CPHM, CFE, CCM, HCAFA).
  • Must possess at least five years clinical experience.
  • At least one year 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.

Qlarant is an Equal Opportunity Employer of Minorities, Females, Protected Veterans, and Individuals with Disabilities.

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