Consultor Especialista em Transformação Digital II
Capco
Job Level
JuniorMid-Level
About the role
- Conducts moderately complex reviews of claims during the course of fraud investigations or other program integrity initiatives such as requests for information or in support of proactive data analysis efforts
- Applies Medicare guidelines in addition to an extensive knowledge of medical terminology and experience in the analysis and processing of Medicare claims in making determinations as to the appropriateness of payment coverage
- Reviews information contained in Standard Claims Processing System files (e.g., claims history, provider files) to determine provider billing patterns and to detect potentially fraudulent or abusive billing practices or vulnerabilities in Medicare payment policies
- Utilizes extensive knowledge of medical terminology and experience in the analysis and processing of Medicare claims and Medicare claims payment systems
- Coordinates and compiles the written Investigative Summary Report to the BI Analyst upon completion of the claims review
- Completes assignments in a manner that meets or exceeds the quality assurance goal for accuracy
- Maintains chain of custody on all documents and follows all confidentiality and security guidelines
- Performs other duties as assigned by Management that contribute to task order area goals and objectives and comply with the Program Integrity Manual and Statement of Work guidelines and CMS directives and regulations
Requirements
- Bachelor’s Degree or equivalent related experience
- 2 - 7 years of experience
- Knowledge of, and the ability to correctly identify, Medicare coverage guidelines
- Must have no adverse actions pending or taken against him/her by any State or Federal licensing board or program
- Must have and maintain a valid driver’s license for the state of residence
- At least two (2) years of experience using medical terminology and experience in the analysis and processing of Medicare claims
- Sitting for long periods
- Standing for long periods
- Ambulate throughout an office
- Ambulate between several buildings
