Trend Health Partners

Auditor

• Review medical records and associated claim information to validate accuracy of DRG assignments and/or Itemized Billing
• Apply coding principles based on industry standards and company/client guidelines
• Validate principal diagnosis, secondary diagnoses, sequencing of diagnoses, discharge statuses and procedures utilizing the medical record
• Apply policies, procedures, guidelines and regulations developed by Centers for Medicare and Medicaid Services (CMS), commercial payers, InterQual, MCG, and Trend Health Partners
• Validate itemized bill payments utilizing the UB-04, the itemized bill and industry/client coding guidelines
• Provide appeal responses for claims of the above types utilizing industry standards and company/client policies
• Assist with new concept development
• Assist with claim selection criteria
• Maintain certifications and continuing education requirements
• May require client communication to support findings

Coder DRG Auditor I

Claims Specialist

• Assist client in identifying, validating, and recovering claim overpayments.
• Validate claims to ensure the accuracy of algorithms and that no refund has previously been posted to the client’s system(s).
• Review and resolve disputed overpayments from client/provider.
• Participate in knowledge sharing to brainstorm and resolve claim issues or seek clarifications.
• Identify new overpayment opportunities and trends by reviewing and researching areas such as CMS and Medicaid claims processing policies, adjustments by client’s internal unit/other vendors, client’s claims processing policies/system(s), provider, and member contracts.
• Interpret and analyze medical and pharmacy claims data as well as provider and enrollment data to accurately assess and demonstrate key insights into trends and opportunities and follow concept development process.
• Assist Management with concept approval information needed for client approval on specific trends.
• Complete step by step instructions for each algorithm moved to production.
• Always represent TREND and our clients in a professional manner.
• Cooperate with team members to meet goals and complete tasks in an efficient and effective manner.
• Provide feedback to Management regarding inventory levels, algorithm effectiveness/productivity, and new trend/ideas.
• Collaborate with TREND Management to identify new opportunities, areas of improvement, and innovate potential solutions.
• Escalate to the manager any situation outside the employee’s control that could adversely impact the business relationship.
• Train and assist new analysts as needed while maintaining high quality and production results.
• Assist with Quality Review process.
• Ensure staff is appropriately resolving day-to-day problems in a timely and successful manner

Claims Analyst III

Data Engineer

• Design, develop, and maintain optimal data pipelines and workflows.
• Provide technical guidance on architecture design and collaborate with Data Engineers for implementation.
• Work with stakeholders to assist with data-related technical issues and support their data infrastructure needs.
• Perform data integration, transformation, and cleaning to create insightful and actionable data for the business.
• Translate business requirements into technical specifications and finished products.
• Participate in code reviews and contribute to team knowledge sharing.
• Lead the development and maintenance of documentation for data engineering processes and systems.
• Create ad-hoc reports requested by internal and external partners.
• Work as a team to support and troubleshoot errors for 100+ data pipelines.
• Work closely with the application development team to update data and data structures.
• Provide analysis, recommendations, and feedback to business process owners, leadership team, and the Information Technology department.
• Propose automated solutions to repeated development tasks.

Data Engineer II

• Acquire knowledge of the client’s claims adjudication system(s), member and provider contracts, and client claim payment policies and procedures.
• Assist client in identifying, validating, and recovering claim overpayments.
• Validate claims to ensure the accuracy of algorithms and that no refund has previously been posted to the client’s system(s)
• Review and resolve disputed overpayments from client/provider.
• Participate in knowledge sharing to brainstorm & resolve claim issues or seek clarifications.
• Identify new overpayment opportunities by reviewing and researching areas such as CMS and Medicaid claims processing policies, adjustments by client’s internal unit/other vendors, client’s claims processing policies/system(s), provider, and member contracts.
• Ideate, test, document & submit new overpayment trends/research scenarios.
• Research potential new ideas and follow algorithm development process.
• Assist Management with concept approval information needed for client approval on specific trends.
• Always represent TREND and our clients in a professional manner
• Cooperate with team members to meet goals and complete tasks in an efficient and effective manner.
• Provide feedback to Management regarding inventory levels, algorithm effectiveness/productivity and new trend /ideas.
• Collaborate with TREND Management to identify new opportunities, areas of improvement and innovate potential solutions.
• Escalate to the manager any situation outside the employee’s control that could adversely impact the business relationship.

Claims Analyst I

Analyst

• Assist providers in identifying, reviewing, and validating patient accounts in a credit balance state
• Manage accounts receivables to ensure timely collection of identified Client overpayments
• Prioritize workload to meet deadlines and goals using guidelines set out by manager
• Achieve individual productivity and quality standards
• Professionally and proactively build relationships and maintain contact with the appropriate personnel at Providers
• Respond to all provider and Client requests in a timely manner
• Escalate to manager any situation outside the employee’s control that could adversely impact the business relationship
• Always represent TREND and our clients in a professional manner
• Cooperate with team members to meet goals and complete tasks

Coder DRG Auditor I

Claims Analyst III

Data Engineer II

Claims Analyst I

Credit Balance Analyst I