IBM Watson Health - Claims Investigator - Truven in DES MOINES, Iowa

Position SummaryTrack the disposition of all cases in the case tracking tool/database and ensure follow up and appropriate disposition of each case for IBM Watson Health's Program Integrity team supporting the Iowa Medicaid Enterprise. Develop provider educational materials. Prepare demand letters and self-audit letters for providers and monitor results. Assist in tracking dollars recovered for each case. This job is a specialized position for which IBM Watson Health will provide training.Essential Responsibilities

  • Monitors the progress of each case within the case tracking system/database and ensures that appropriate actions are taken.

  • Works collaboratively with the other members of the IBM Watson Health Program Integrity team for the Iowa Medicaid Enterprise to determine the status and final disposition of each case.

  • Prepares demand letters and other notifications for providers and ensures that the customer/appropriate staff person has approved all letters before they are sent out where necessary.

  • Responds to provider inquiries regarding the status of an investigation or audit and ensures a prompt and provider-friendly approach.

  • Coordinates the appeals process for providers as needed with the Team's Audit subcontractor.

  • Assists with notifications, tracking, collection and reporting of overpayment recoveries, including working within the Medicaid claims system to process claims adjustments reflecting overpayments recovered/changes in payment initiated.

  • Works with team members to develop appropriate educational materials for providers.

  • Assists in developing policies, procedures, processes and workflows to support the Audit and Case Disposition Process.

  • Provides input into the configuration, testing, implementation and ongoing operations of the Case tracking system/database.

  • Coordinates activities and case dispositions with other functional teams as needed.

  • Recognize situations requiring urgent attention and manages situation through to resolution via escalation and timely communication.

  • Strong initiative and adept at ability to plan and prioritize work efficiently, multi-task, and work well under pressure with minimal direction.

  • Experience within the healthcare industry related to coding, billing or auditing OR government sector (including Medicare or Medicaid).

  • Experience with Microsoft Excel, Word and PowerPoint.

  • Demonstrates excellent oral and written communication skills.

  • Ability to work within well-defined processes that leave room for independent judgment.

  • Ability to work well with others in a team oriented environment and to gain their cooperation.

IBM is committed to creating a diverse environment and is proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status. IBM is also committed to compliance with all fair employment practices regarding citizenship and immigration status.