Health Management Systems, Inc. Medical Claims Recovery Specialist II in Las Vegas, Nevada

HMS makes the healthcare system work better for everyone. We fight fraud, waste, and abuse so people have access to healthcare—now and in the future. Using innovative technology and powerful data analytics, we help government and commercial payers reduce costs, increase quality, and achieve regulatory compliance. We also help consumers take a more active role in their own health. Each year, we save our clients billions of dollars while helping people live healthier lives. At HMS, you will develop new skills and build your career in a dynamic industry while making a difference in the lives of others.

We are seeking a talented individual for a Research Analytics & Development (RAD) Specialist II who performs research analytics to support our recovery audit line of business. Assists in the development and implementation of new data mining and audit/review methodologies for identifying healthcare overpayments and underpayments to providers, and the detection of healthcare fraud, waste, and abuse.

Essential Responsibilities:

  • Researches local billing and reimbursement policies, client reimbursement practices (through review of manuals/regulations and meetings with stake holders) to develop and configure overpayment algorithms. Organizes, documents, and communicates results.

  • Applies knowledge of provider billing and patient accounting practices to research of client policy and data to reveal new overpayment recovery opportunities. Works with data miners, clinical staff, and stakeholders to identify new overpayment issues for each client.

  • Participates in the review of health insurance claims and member eligibility information to uncover claims overpayment trends associated with non-compliance or misapplication of contract terms and rates, payment policies, medical policies, billing guidelines, and applicable regulatory requirements.

  • Develops specifications for IT programming related to overpayment algorithms and analysis.

  • Reviews IT programming results for quality assurance and proof of concept validation.

  • Documents results and supports preparation of internal and external documentation and presentations related to research and new overpayment issues.

  • Works with internal operations and clinical teams to develop and implement review/audit/recovery protocols and internal review guidelines.

  • Tracks, and follows-up on results and recoveries.

  • Develops and validates workflows and communication tools to best enhance audit production, client satisfaction, and quality assurance.

  • Works with IT to develop and implement technological improvements that will support the audit process.

  • Develops business criteria to maximize the identification of contractual & billing compliance audit recovery opportunities.

  • Contributes new ideas for improving existing audit processes and audit queries.

  • Works cohesively with the audit team and the client

  • Develops, maintains, and ensures adherence to multiple project schedules.

  • Assists in preparing presentations and proposals to internal and external clients.

Non-Essential Responsibilities:

  • Performs other functions as assigned

Knowledge, Skills and Abilities:

  • Excellent conceptual and analytical skills

  • Good project management skills

  • Ability to develop, organize, and maintain project plans and agendas

  • Ability to effectively interface with clients on the phone and in person

  • Strong working knowledge of Microsoft Suite of products (Excel, Word, Access)

  • Basic Knowledge of SQL

  • Understanding or medical terminology and anatomy.

  • Understanding of Medicaid required, Medicare and commercial experience a plus.

  • In depth knowledge of coding principals including but not limited to NCCI Edits, CPT, HCPCS and ICD-9 codes and modifiers; and/or MSDRG, Revenue codes, and APCs

  • In depth knowledge of UB04 and medical (1500) claim formats and requirements.

Work Conditions and Physical Demands:

  • Primarily sedentary work in a general office environment

  • Ability to communicate and exchange information

  • Ability to comprehend and interpret documents and data

  • Requires occasional standing, walking, lifting, and moving objects (up to 10 lbs.)

  • Requires manual dexterity to use computer, telephone and peripherals

  • May be required to work extended hours for special business needs

  • May be required to travel at least 20% of time based on business needs

Minimum Education:

  • High school diploma or GED required; Bachelor’s degree preferred

Minimum Related Work Experience:

  • 4 years of healthcare reimbursement experience such as provider contract development, healthcare claims analysis, medical billing/coding, patient accounting, claims auditing, and/or revenue cycle improvement required

  • Must have demonstrated experience and knowledge of healthcare claims processing (Medicaid, Medicare, Commercial Insurance), including ICD-9-CM codes, HCPCS codes, CPT codes, DRGs, physician billing, etc. preferred

  • Experience in healthcare auditing, reviewing and validating the accuracy of claims data and accuracy of claims payment preferred

  • Experience applying published healthcare guidelines such as CMS regulations and coding guidelines to healthcare claims data, Recovery audit experience is preferred

Nothing in this job description restricts management’s right to assign or reassign duties and responsibilities to this job at any time.

Title: Medical Claims Recovery Specialist II

Location: Nevada-Las Vegas

Requisition ID: 180010XX

EEO/Minorities/Females/Protected Veterans/Disabled.