Conducts moderately complex reviews of claims during fraud investigations or other program integrity initiatives. Applies Medicare guidelines, medical terminology, and experience in Medicare claims analysis to determine payment appropriateness. Reviews claims processing system files to detect fraudulent billing practices and vulnerabilities. Coordinates the written Investigative Summary Report.
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Analyzes and reviews claims for accuracy, completeness and eligibility. Prepares and maintains reports and records for processing. Familiar with standard concepts, practices, and procedures within a particular field. Relies on limited experience and judgment to plan and accomplish goals. Performs a variety of tasks.
Responsible for managing and executing all billing functions within skilled nursing facilities, with a particular emphasis on Illinois Medicaid billing. Requires a comprehensive understanding of all payer types and the ability to ensure accurate and timely billing processes. Responsibilities include billing operations, claims management, documentation and reporting, collaboration and communication, and regulatory compliance.