Job Description

Introduction
At IBM, work is more than a job its a calling: To build. To design. To code. To consult. To think along with clients and sell. To make markets. To invent. To collaborate. Not just to do something better, but to attempt things youve never thought possible. Are you ready to lead in this new era of technology and solve some of the worlds most challenging problems? If so, lets talk.

Your Role and Responsibilities
Review and monitor health claims for the identification of aberrancies and possible provider fraud, waste and abuse. Develop provider education, demand letters, and self-audit letters and tracking the disposition of all cases in the case tracking tool/database and ensure follow up and appropriate disposition of each case for IBM Watson Healths Program Integrity team supporting the Iowa Medicaid Enterprise. Document key milestones in provider investigations and assist in identifying opportunities for policy alignment and cost savings for the IBM Watson Health Program Integrity team that supports Iowa Medicaid.

Responsibilities and Expectations

* Reviews claims data and reports to identify aberrant providers for possible audits.
* Monitors the progress of each case within the case tracking system/database and ensures that appropriate actions are taken.
* Works collaboratively with the other members of the IBM WatsonHealth Program Integrity team for the Iowa Medicaid Enterprise to determine the status and final disposition of each case.
* Prepares demand letters and other notifications for providers and ensures that the customer/appropriate staff person has approved all letters before they are sent out where necessary.
* Responds to provider inquiries regarding the status of an investigation or audit and ensures prompt and provider-friendly approach.
* Coordinates the appeals process for providers as needed with the Teams Audit subcontractor.
* Assists with notifications, tracking, collection and reporting of overpayment recoveries, including working within the Medicaid claims system to process claims adjustments reflecting overpayments recovered/changes in payment initiated.
* Works with team members to develop appropriate educational materials for providers.
* Assists in developing policies, procedures, processes and workflows to support the Audit and Case Disposition Process.
* Provides input into the configuration, testing, implementation and ongoing operations of the Case tracking system/database.
* Coordinates activities and case dispositions with other functional teams as needed.
* Excellent oral and written communication skills.
* Recognize situations requiring urgent attention and manages situation through to resolution via escalation and timely communication.
* Strong initiative and adept at ability to plan and prioritize work efficiently, multi-task, and work well under pressure with minimal direction.
* Ability to work within well-defined processes that leave room for independent judgment.
* Ability to work well with others in team-oriented environment and to gain their cooperation.

Required Technical and Professional Expertise

* Requires 2 year college degree, preferably in health sciences.
* Minimum 3 years of experience with healthcare claims and/or health care fraud/program integrity.
* At least 3 years of experience in customer service, administrative support and/or data entry within the healthcare, insurance or government sector.
* Minimum 2 years of coding experience including Coding credentials such as RHIT, CCS, or CCS-P

Preferred Technical and Professional Expertise

* Medical record review experience and/or clinical background such as RN or LPN
* Experience in Excel, preparing graphs, trending data, and conducting presentations strongly preferred.
* Prior experience working collaboratively with health care providers is strongly preferred.
* Prior experience working collaboratively with health care providers is strongly preferred.