Summary
 

Review claims processing, membership functions, managed care functions, and how finance handles state-dated checks, looking for problems that might result in over or underpayments. Also, maintain lists of items uncovered and continuously monitor the new procedures to ensure fixes put in place are maintained.

Description
 

Logistics: This role is onsite at the Atrium Building – 2401 Faraway Drive, Columbia, SC.

We are interested in every qualified candidate who is eligible to work in the United States. However, we are not able to sponsor visas for this position.

What You’ll Do:

• Direct the review and audit of claims and membership to identify lost revenue, overpayments, and fraud/abuse patterns. Design and implement corrective procedures, work with overpayment staff to make recoveries, and identify proactive mechanisms for avoiding overpayments. Primary person responsible for generating ideas and initiatives focused on overpayment and recovery. Responsible for overseeing and managing overpayment, recovery, or DRG validation vendors. Direct Operations staff in corrective actions designed to eliminate operational errors, which result in inaccurate claims payments.

• Analyze data requirements of CHC and assist in developing and implementing programs based on analysis. Direct Operations analyst in developing data queries and reports used to identify payment patterns, payment problems, and fraud. Responsible for ongoing review and maintenance of corrective actions.

• Review and analyze private sector claims and healthcare practices to determine healthcare trends and payment patterns affecting the corporation's overall underwriting/actuarial goals. Utilize data to formulate actions to reduce costs. Include analyzing data from multiple departments to assist in meeting corporate cost containment objectives. Responsible for meeting savings goals resulting from audits. Develop and maintain PC databases and spreadsheets to collect and report data. This includes oversight of extracting, analyzing, and joining data from the mainframe, PC, and other vendor databases

• Ensure that quality, professional management-level reports are prepared based on analysis of available data. Develop and implement action plans to aid in controlling costs and recovering overpayments. Assume responsibility for any corporate tasks assigned by the Executive vice president. Perform special reviews and research as directed by senior management.

To Qualify for This Position, You'll Need the Following:

• Required Education: Bachelors in a job-related field.

• Degree Equivalency: Four (4) years job related work experience or Associate's and 2 years job related work experience (Equivalency not applicable for the Celerian Group, Bachelor’s degree required).

• Required Experience: Four (4) years of healthcare industry finance and deliver areas including executive and institutional providers. Four (4) years of experience managing or leading staff that perform data management and analysis functions.

• Required Software and tools: Microsoft Office. Basic knowledge of DB2.

• Required Skills and Abilities: Knowledge of managed care principles, insurance, and reimbursement methodologies. Working knowledge of insurance contracts, claims, membership, and care management. Understanding of healthcare delivery and reimbursement systems. Excellent verbal and written communication skills. Ability to organize, prioritize, and