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Senior Executive

4 weeks ago

Chennai, Tamil Nadu, India EXL Service Full time

Senior executive SIU Investigator Special Investigation Unit More than 5 years of experience in surgery coding is a must The Fraud and Waste Professional conducts investigations of allegations of fraudulent and abusive practices and assists investigators with law enforcement activities The Senior Specialist Medical Coding Auditor SIU works to support in assessing trends and patterns in FWA across the healthcare industry using deep coding knowledge to audit prepayment and or post payment claims Assembles evidence and documentation to support successful adjudication where appropriate Conducts audits of provider records ensuring appropriateness of billing practices and coding services rendered is complete compliant and accurate to support optimal reimbursement Understands own work area professional concepts standards regulations strategies and operating standards Makes decisions regarding own work approach priorities and follows direction Work is managed and often guided by precedent and or documented procedures regulations professional standards with some interpretation Responsibilities Develops and maintains a depth of expertise on CPT HCPCS and ICD-10 Coding guidelines and other insurance billing submission requirements Perform complex policy updates or audits of assigned documentation i e medical records or claims on both a prepayment and or post payment basis to determine accuracy of claims Understanding of healthcare industry claims processing and investigative process Education Bachelor s or Advanced degree in Nursing or related field Experience Five years coding or auditing experience across multiple specialties in the health insurance industry and or healthcare fraud investigations Preferred qualifications include one-year leading projects of varying size and complexity three years of financial analysis in a healthcare setting and three years in professional billing Licenses Certifications Certified Professional Coder CPC Certified Coding Specialist CCS Skills Knowledge of provider payment methodologies claims processing systems coding and billing strong computer skills and the ability to use data mining tools excellent communication written and oral relationship-building skills strong business acumen ability to work independently and as part of a team and problem-solving capabilities knowledge and understanding of healthcare fraud schemes and trends are key Emphasis on serving as a subject matter expert providing guidance and training to other team members and potentially leading special projects Strong ability to comprehend and explain complex processes end-to-end and identify risks and mitigating controls EXL Service