SPE-Ins Claims

Cognizant Consulting; Philippines; On-site; PHP 360,000 - 540,000; Full time

Job summary

Cognizant Consulting in the Philippines is seeking a detail-oriented nurse to perform intensive medical bill audits. The role involves examining hospital, DME, pharmacy, and home health bills, validating services rendered against reports, and ensuring proper coding in accordance with fee schedules and internal policies.

The successful candidate will leverage the Medical Bill Repricing System to assess accuracy, detect duplications, and make informed payment recommendations.

Qualifications

• Performs intensive medical bill audits to detect duplicates, outliers, potential fraud, and incorrect coding.

Responsibilities

• Review medical hospital, DME, pharmacy, and home health bills for accuracy.
• Read and interpret scanned medical reports using the Medical Bill Repricing System to verify services billed reflect services provided.
• Compare bills and rates with fee schedules and internal guidelines to determine appropriate payments.
• Identify overlaps or duplications of services across bills.
• Apply payment policies to medical supplies and drugs/medicine.
• Provide accurate payment recommendations based on analysis of each bill.

Skills

Medical bill audit

Fraud detection

Coding accuracy

Regulatory knowledge

Bill review

Education

Philippine Licensed Registered Nurse

Tools

Medical Bill Repricing System

Job description

Job Summary

Performs an intensive and detailed medical audit of bills to detect duplicates outliers potential fraud and inappropriate coding potential overutilization and full research of regulatory fee schedule for Workers Compensation. Nurses review all bills that are under Surgery and Anesthesia product

Responsibilities

Performs a detailed review of submitted medical hospital durable medical equipment pharmacy home health bills along with accompanying reports information for accuracy and to determine appropriateness

Using multiple screens on the Medical Bill Repricing System read and interpret scanned medical reports to determine that services on bill were actually performed and coded to reflect the services that were actually provided

Compare bill and rates with appropriate fee schedules clinical edits Medicare National Correct Coding Initiative NCCI internal protocols to determine appropriate payment recommendations

Compile all medical bills to determine if there is overlap or duplication of any services

Apply payment policies to medical supplies and drugs/ medicine

Make accurate payment recommendations based on the results and analysis of each medical bill

Certifications Required

Philippine Licensed Registered Nurse