PACE Health Care Senior Consultant

CBIZ•Atlanta, GA

5d•Hybrid

About The Position

The Health Care Senior Consultant will independently review/audit medical records associated with claims and work in a team environment on fraud, waste and abuse and program compliance issues for engagements with government healthcare programs, including primarily the Medicaid and Medicare programs. Utilizing healthcare knowledge and experience to review medical records for various types of medical services for accuracy, completeness and consistency with professional standards and compliance with billing and coding requirements. Documenting and reporting findings of reviews and audits in accordance with professional standards and project protocols. Participating in on-site field examinations of providers to review clinical documentation. Interpreting and analyzing health care data. Working with state client personnel on health care reimbursement and compliance issues, including recommending changes and improvements of policies to ensure provider compliance. Working collaboratively with the medical director and other clinical staff in the development and management of fraud, waste and abuse detection and other compliance projects. Developing and maintaining general knowledge of reimbursement regulations, provider billing manuals and other Medicaid policies for claim payment compliance reviews and documentation to support current audit findings. Participating in and contributing to quality management systems. Maintaining security of and confidentiality of all protected health information (PHI).

Requirements

High school diploma or GED
At least 3 years of related experience
Experience and knowledge of state and federal healthcare regulations, including reimbursement and coverage policies
Proficient use of applicable software tools, including Microsoft Windows, Word, Excel, and Access
Strong analytical and problem-solving skills
Excellent communication skills including written and verbal, including ability to present to large or small groups
Self-directed and motivated, with ability to work independently under general instructions
Ability to work in a team environment and manage multiple deadlines and prioritize assignments
Well organized with a high degree of accuracy and attention to detail

Nice To Haves

Bachelor's degree in related field or equivalent experience
Certification
Experience in quality improvement projects desired
Ability to travel based on client and business needs

Responsibilities

Independently review/audit medical records associated with claims.
Work in a team environment on fraud, waste and abuse and program compliance issues for engagements with government healthcare programs, including primarily the Medicaid and Medicare programs.
Utilize healthcare knowledge and experience to review medical records for various types of medical services for accuracy, completeness and consistency with professional standards and compliance with billing and coding requirements.
Document and report findings of reviews and audits in accordance with professional standards and project protocols.
Participate in on-site field examinations of providers to review clinical documentation.
Interpret and analyze health care data.
Work with state client personnel on health care reimbursement and compliance issues, including recommending changes and improvements of policies to ensure provider compliance.
Work collaboratively with the medical director and other clinical staff in the development and management of fraud, waste and abuse detection and other compliance projects.
Develop and maintain general knowledge of reimbursement regulations, provider billing manuals and other Medicaid policies for claim payment compliance reviews and documentation to support current audit findings.
Participate in and contribute to quality management systems.
Maintain security of and confidentiality of all protected health information (PHI).