Sagility combines industry-leading technology and transformation-driven BPM services with decades of healthcare domain expertise to help clients draw closer to their members. The company optimizes the entire member/patient experience through service offerings for clinical, case management, member engagement, provider solutions, payment integrity, claims cost containment, and analytics. Sagility has more than 25,000 employees across 5 countries.
The Senior Executive will be responsible for ensuring accurate identification of a clients claim payment anomalies by obtaining the clients provider agreements and contract loading, researching and flagging discrepancies, and validating claims for payment integrity. This role involves collaborating with various departments, using system tools to load contracts, identify claim anomalies, and ensure compliance with healthcare regulations and company policies.
The specialist will play a key role in ensuring claims anomalies are accurately and efficiently identified and submitted to the client for recovery of the overpaid claims.
Key Area of Responsibilities:
Contract Loading & Maintenance:
- Accurately load, configure, and maintain healthcare provider contracts within the audit and claims systems, ensuring alignment with contractual terms.
- Review and update contract details including fee schedules, reimbursement rates, and payment terms to support accurate claims adjudication.
- Ensure timely and exact updates to contract data, reflecting the most current agreement terms and minimizing payment discrepancies.
Claims Flagging:
- Review claims flagged by the audit system as potentially overpaid to confirm validity and ensure they meet overpayment criteria.
- Validate the allowed claim amount against independent sources outside of both the client and Sagility to ensure objective verification.
- Identify and flag claims that appear non-compliant with contract te