Sagility combines industry-leading technology and transformation-driven BPM services with decades of healthcare domain expertise to help clients draw closer to their members. The company optimizes the entire member/patient experience through service offerings for clinical, case management, member engagement, provider solutions, payment integrity, claims cost containment, and analytics. Sagility has more than 25,000 employees across 5 countries.
Job title:
Job Description:
We are currently hiring a talented Pricing Research Analyst/Consultant to research, understand and then create pricing methodologies to be loaded into propriety claims audit software for the purpose of accurately pricing healthcare claims. Working with the Information Technology group, the Pricing Research Analyst/Consultant will serve as the direct point of contact for research and implementation of multiple State Medicaid and Medicare (CMS) pricing methodologies primarily focused on institutional (hospital) inpatient and outpatient claims. This role is paramount to company success – an intrinsic curious, self-motivated, persevering, goal-oriented mindset is a must.
Responsibilities:
Create and update pricing spreadsheet capturing variables from various sources to ensure current and accurate pricing is uploaded and used in claims pricing.
Autonomously and consistently research resources that would provide the data needed for current, accurate and updated regulations and pricing.
Review claims payments for inconsistencies related to reimbursement, acting as a subject matter expert for consultant questions relating to pricing.
Partner with IT team to relay formulas and necessary data to upload into the pricing software for claims review.
Partner with training to create step by step guides for end users to understand and utilize the pricing engine and claims auditing.
The ideal candidate will possess:
Five years of demonstrated success auditing institutional (hospital) inpatient and outpatient claims. For example (APR DRG, MS DRG, per diem, including outlier and contract as well as State carveouts) and outpatient (cost-based recoveries using cost-to-charge ratios, APC, EAPG also including outlier and contract rates as well as State carveouts) for recovery of overpayments in a consulting or provider/payer environment.
Healthcare industry experience researching State and Federal regulations to identify the pricing variables required to accurately price claims.
The ability to communicate pricing formulas in a format which the Information Technology (IT) group can utilize to build pricing engines.
Ability to document processes and work with the Documentation team to create high level audit resources for each state, claim type (inpatient vs. outpatient) and line of business that can be used by the Audit team to validate overpayments.
Strong problem solving
Diligence in reviewing and ensuring ongoing updates to pricing variables by maintaining knowledge of State and CMS website transmittals and updates.
Excellent communication and interpersonal skills - the ability to work successfully with internal teams and external clients.
High Implementation of research into claims review software (pricing engine) experience a strong plus.
Advanced Microsoft Office skills, especially Excel and Word.
EDUCATION
High School Degree or GED required.
BA/BS in Business Administration or related field a strong plus, experience will be considered to offset educational requirements.
Certified Inpatient Coder (CIC) a plus
Salary: Starting at $120,000.00 and up dependent on experience
Sagility Offers Competitive Benefits Including:
Medical
Dental
Vision
Life Insurance
Short-Term and Long-Term Disability
Flexible Spending Account
Life Assistance Program
401K with employer contribution
PTO and Sick Time
Tuition Reimbursement
Join our team, we look forward to talking with you!
An Equal Opportunity Employer/Vet/Disability
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