COORD. MEDICO UNIDAD FAWE

DATOS DEL PUESTO

Supervisa (Total)

PRINCIPALES ROLES Y RESPONSABILIDADES

OBJETIVO

To meticulously assess and enhance the integrity of medical claims processes through comprehensive clinical reviews and casework, ensuring accuracy and adherence to billing principles. The aim is to proactively identify, prevent, and mitigate fraud, waste, abuse, and errors in across the claims fund, collaborating effectively with stakeholders.

Funciones

Clearly define the objectives and scope of medical reviews. Determine the specific areas, processes, or aspects of treatment that will be assessed, such as coding accuracy, medical necessity, invoicing accuracy, service utilisation patterns, or poor or inappropriate treatment.
Identify the medical records or claims for review. This can be based on specific criteria, such as high-cost procedures, high-cost treatment, speciality type, specific provider or provider group or practitioner. The reviews will also be driven by referrals from the FAWE team auditors and investigators who will initially decide on the audit criteria and objectives.
Collect all relevant documentation including medical records, invoices, underwriting terms and policy information, and other supporting documentation necessary for the work. 
Evaluate the accuracy and completeness of the medical records and request further information if required.
Review the selected medical records or claims, focusing not just on the initial objectives but any other concerns or issues identified during the review process. Assess the coding used in the medical records or claims. Verify whether the assigned diagnosis and procedure codes accurately reflect the services provided and invoiced. Check for any discrepancies or errors in coding.
Determine whether the documented medical services are medically necessary and appropriate for the patient's condition including, surgery or treatment performed, pathology ordering, radiology usage, drug prescribing.
Evaluate adherence to any pre-authorised treatment and agreed fee amounts.
Review underwriting terms and consider if the treatment provided should have been covered.
Evaluate the medical records or claims for compliance with best practice guidelines, and policy rules. 
Identify any potential instances of FAWE or deviations from accepted practices or billing guidelines, such as unbundling, over-servicing, and misrepresentation.
Document the findings of the review, including any discrepancies, errors, compliance issues, or areas of improvement.
Based on the findings, formulate recommendations for improvement in the claims or underwriting processes, strategies to deal with poor practice and to reduce claims cost leakage.
Present the review findings and recommendations to the internal stakeholders such as the FAWE team manager and specialists, Risk and Internal Control, SIU, senior management and external entities such as law enforcement, regulators, practitioners, and providers.
Track the implementation of the recommended changes or actions resulting from the work. Monitor the progress, assess the effectiveness of the interventions, and provide ongoing support or guidance as needed.
Identify areas of claims cost leakage and collaboratively develop new processes and procedures to control FAWE at the policy inception, authorisation/claim and payment levels.
Evaluate emerging medical technologies, treatments, and procedures to determine their efficacy and appropriateness for coverage and help develop clear policies, that prevent claims for non-evidence-based or experimental treatments.
Collaborate with regulatory bodies, industry stakeholders and law enforcement to share information and coordinate efforts in detecting and preventing fraud. Participate in industry forums and working groups to exchange knowledge and best practice.
Work collaboratively with FAWE analysts to devise new techniques of leveraging data and developing algorithms to identify potential FAWE. 
Leverage the collective experience and knowledge of other medical professionals within the business to identify areas of claims cost leakage, and work with them to develop new preventative strategies.

REQUERIMIENTOS

Disponibilidad para viajar

Escolaridad

Área de Formación

Desirable:
o Previous experience in medical auditing, coding, or claims review.
o Knowledge of medical coding systems, such as ICD-10-CM, CPT, and HCPCS,
and their application in health insurance.
o Familiarity with healthcare regulations, policies, and guidelines, including
those related to health insurance and fraud prevention.
- Essential:
o Active medical license in good standing

Conocimientos Especiales y/o Certificaciones

Medical degree from a recognized institution

Nivel de Inglés

Experiencia

Nivel de Experiencia