Job Description:
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Department Overview
The Cahaba Safeguard Administrators, LLC Benefit Integrity units identify, investigate and reduce fraud and abuse to the Medicare Program and support law enforcement with these investigations. Benefit Integrity Investigations, Medical Review and Data Analysis partner to identify potential aberrancies that require further review to determine whether an actual loss to the Medicare/Medicaid Program has occurred. Once potiential fraud and abuse has been identified, the Benefit Integrity unit coordinates appropriate strategies for investigations.
General Responsibilities
This position is responsible for conducting medical review activities related to benefit integrity for Medicare Part A, Part B, Part C, Home Health, Hospice and Part D Prescription Drug claims utilizing professional medical knowledge to determine the appropriateness of payment for medical services according to the Social Security Act; Codes of Federal Regulations; National Coverage Determinations; Local Coverage Determinations; Medicare/Medicaid coverage eligibility and reimbursement requirements. The incumbent will coordinate resolutions of program integrity cases within CSA's other departments, law enforcement agencies, CMS, QIO and AC/MAC, Medicaid, etc.
Qualifications
1. Bachelor degree or, upon hire, commit to actively pursue a degree
2. Active license as a Registered Nurse (RN)
3. Currently licensed by the State of Texas as a Registered Nurse or, upon hire, agree to actively pursue Texas license
4. Minimum of 5 years clinical experience as an RN
5. Minimum of 2 years experience with utilization/medical review
6. Experience in a position utilizing Medicare coverage guidelines and payment methodologies
7. Experience in a position communicating and interpreting information orally and written
8. Experience in a position exercising independent judgment and decision making
9. Experience in a position analyzing information to solve problems 10. Proficient in using a PC and keyboard in a Windows environment
11. Experience working with ICD-9-CM/CPT-4 coding preferred
12. Experience in a position reviewing NCPDP and other types of prescription drug claims is preferred
13. Experience in a position working with Medicare Part A, Part B, DME, and home health/hospice is preferred
Work Schedule
The hours for this position are 8:00 a.m. to 4:45 p.m.
Conditions of Employment
Applicants selected for employment will be required to pass a pre-employment drug screening and background investigation which may include education, criminal, and work history verifications.
In Conclusion
Thank you for your interest in Cahaba Safeguard Administrators, LLC. We look forward to receiving your application. Upon review, if you can be considered further you will be contacted by one of our Corporate Staffing representatives.
Again, thank you for your interest in our company.
Cahaba Safeguard Administrators, LLC is an affirmative action and equal opportunity employer. As such, it is our policy to provide equal opportunity for all qualified persons and not discriminate against any associate or applicant for employment because of race, religion, color, sex, sexual orientation, age, national origin, handicap, disability, or because he or she is a disabled veteran or a Vietnam Era Veteran.
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