Consultant / SME Domain

Job Title:

Job Description

• The Consultant/SME (US healthcare) will be responsible for developing/strengthening the concept/rule pipeline across line of businesses i.e. Commercial and Medicare plans. The individual will be responsible for auditing client data on behalf of Concentrix clients and generating high quality recoverable claims for the benefit of Concentrix and our clients, as well as conducting or assisting in the identification, validation, and documentation of moderate to more complex audit projects. This role will be primarily responsible for auditing efforts by executing more independent projects, low to mid-range in scope assigned by the Manager

• Implement the pre-payment and retrospective review processes that are consistent with established industry and corporate standards and are within the Payment Integrity Clinician’s professional discipline.
• Implement all reviews according to accepted and established coding criteria, as well as other approved guidelines, payment, and medical policies.
• Act as a resource and subject matter expert to colleagues with less experience on a frequent basis to problem solve through Payment Integrity Review issues that would be considered of medium to high degree of complexity.
• Ability to visualize, articulate and solve complex problems representative of a broad range of service and claim scenarios.
• The incumbent is expected to utilize specialized skills and knowledge to achieve successful and measurable outcomes.

Required Skills

• 3+ years of proven clinical experience in US payment integrity.
• Strong working knowledge and understanding of healthcare industries preferred.
• Investigative skills, including the ability to evaluate facts and evidence to draw conclusions, even if information is limited as well as explain problems or situations using a systematic framework.
• Strong communication skills, including ability to build relationships and articulate thoughts clearly and effectively.
• Ability to handle multiple projects, prioritize and meet deadlines.
• Exhibits behaviors consistent with Concentrix values & principles.
• Team player that works collaboratively with various team members to accomplish integrated solutions.

Education & Experience

• Bachelor’s Degree or equivalent combination of experience in health insurance or related fields, which would provide the necessary knowledge, skills, and abilities to successfully perform the work.
• Coding Certification (CPC, CCS, CPMA or equivalent)
• Five to seven plus years of experience in medical claims review or claims processing
• Proven analytic expertise using Microsoft Excel and Access, database query capabilities, and ability to evaluate data at all levels of detail
• Experience with manipulating large datasets
• Experience concisely communicating complex analyses to gain consensus across departments on overpayment items
• Experience turning internal recommendations and industry concepts into potential cost saving.
• Experience with medical terminology, claim audit procedures, provider contracts, claims processing procedures and guidelines.

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