· Job Description:
DXC Technology (NYSE: DXC) is the world’s leading independent, end-to-end IT services company, helping clients harness the power of innovation to thrive on change. Created by the merger of CSC and the Enterprise Services business of Hewlett Packard Enterprise, DXC Technology serves nearly 6,000 private and public sector clients across 70 countries. The company’s technology independence, global talent and extensive partner alliance combine to deliver powerful next-generation IT services and solutions. DXC Technology is recognized among the best corporate citizens globally. For more information, visitwww.dxc.technology .
The Insurance/Healthcare job family contains positions associated with providing consultancy utilizing knowledge and expertise on insurance and healthcare. Develops and implements general insurance and health policies in accordance with state and federal laws. Provides expertise to investigate and adjudicate claim characteristics that do not match policy provisions. Responds to provider appeals and meets with providers to resolve problems/issues. Provides directions for utilization review. Approves any remedial or recoupment actions associated with escalated claims. Advises provider review councils, state officials and works with organized healthcare groups and associations on various medical issues related to insurance and healthcare programs
· The surveillance and utilization review analyst applies clinical knowledge to Medicaid claim data to identify possible issues of fraud or abuse of Medicaid benefits, quality of care concerns or non compliance with existing policy.
· The analyst researches individual cases, summarizes the findings and presents recommendations to the customer using independent clinical judgement and established protocols.
· The recommendations may include recoupment or adjustment of claims, referral to the Medicaid Fraud Control Unit (MFCU), referral to the Department of Health or other agencies. The analyst may be required to testify in court if a case goes to court.
· Cases are often complex requiring in depth research of community medical standards, existing policy and procedures and knowledge of claims processing.
· Presentations of findings are both written and oral and are shared with a wide audience.
· Registered Nurse with at least 5 years of clinical experience required
· Excellent verbal, written and analysis skills required.
· Working knowledge of applications such as Excel, Word, Outlook, etc.
· Coding experience (CPT, ICD10, HCPCS) necessary
· Familiarity with claim review
· Prior utilization review experience a plus
· Able to work in a small team