Job Description:
TogetherMD (TMD) is a pioneering data analytics and revenue cycle firm transforming the healthcare industry. Leveraging advanced machine learning and automation, TMD partners with hospitals and health plans to enhance reimbursement accuracy by identifying and correcting misclassified diagnoses. Our innovative approach saves healthcare facilities millions annually, blending state-of-the-art technology with expert professionals to ensure meticulous documentation of provider services.
Role Overview:
As a DRG Recovery Auditor, you will be crucial in ensuring the accuracy and compliance of health plan claims according to established policies, procedures, and contractual obligations. Your responsibilities will include pre-payment and post-payment validation, managing operational reporting, testing, and data submissions.
Key Responsibilities:
- Apply Medicare Claim Payment rules, including National Coverage Decisions and Correct Coding requirements.
- Conduct pre-payment and post-payment payer-side audits to verify coding accuracy and adherence to adjudication rules.
- Manage high-dollar claim audits and resolve complex or escalated claims utilizing extensive knowledge of Medicare payment rules.
- Collaborate with providers to ensure Medicare criteria are met before approving payment claims by validating necessary medical records.
- Ensure claims payments comply with contractual agreements, maintaining a minimum accuracy rate of 98%.
- Identify and address third-party liability cases, coordinating efforts for recovery.
- Educate providers on billing requirements and prior authorization processes.
- Review and process provider payment disputes and member reimbursement requests.
- Generate and distribute claim inventory and aging reports as needed.
- Validate claim reports before submission to regulatory entities.
- Support appeals processes and assist in resolving payment disputes.
- Identify and report potential fraud and abuse cases.
- Communicate trends to aid in the development of provider training programs.
- Identify opportunities for process improvements and assist in system implementations.
Minimum Requirements:
- Strong clinical medical background (e.g., RN, NP, PA, or foreign graduated medical doctors) with CDI experience and DRG validation experience required.
- Minimum five years of healthcare claims processing experience or equivalent, with at least three years of experience on the health plan side.
- Managed care experience required.
- Proficiency in health insurance business, industry terminology, and regulatory guidelines.
- Strong understanding of Medicaid and Medicare claim processing.
- Expertise in medical terminology, ICD-10-CM coding, and DRG codes.
Job Types: Part-time, Contract
Schedule:
Monday to Friday
- Weekends as needed
Work Location: Remote
Salary: $40 per hour (commensurate with experience)
Job Types: Full-time, Contract
Pay: $40.00 per hour
Expected hours: 8 – 10 per week
Schedule:
- Monday to Friday
- Weekends as needed
Work setting:
Experience:
- payer-side DRG auditing: 3 years (Preferred)
Work Location: Remote