20 days old

Watson Health - Business Analyst - Claims Investigator

Des Moines, IA 50309
  • Job Code

IBMs Industry Consultants are essential to our clients as they work to reinvent themselves for the future. Join our highly visible and highly skilled team of global consultants as we strive to accelerate sales, deliver client engagements, and build IBMs market eminence. If you are a forward-thinker and a curious intellectual, we welcome you to apply for your next exciting career challenge!

Your Role and Responsibilities
Location: You will be working on-site at the client's downtown location in Des Moines.

Review and monitor health claims for the identification of aberrancies and possible provider fraud, waste and abuse. Develop provider education, demand letters, and self-audit letters and tracking the disposition of all cases in the case tracking tool/database and ensure follow up and appropriate disposition of each case for IBM Watson Healths Program Integrity team supporting the Iowa Medicaid Enterprise. Document key milestones in provider investigations and assist in identifying opportunities for policy alignment and cost savings for the IBM Watson Health Program Integrity team that supports Iowa Medicaid.

  • Reviews claims data and reports to identify aberrant providers for possible audits.
  • 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 prompt and provider-friendly approach.
  • Coordinates the appeals process for providers as needed with the Teams 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.
  • Strong initiative and adept at ability to plan and prioritize work efficiently, multi-task, and work well under pressure with minimal direction.

Required Technical and Professional Expertise
  • 3+ years coding experience required.
  • 3+ years experience processing and working with claims
  • 3+ years experience in customer service, administrative support and/or data entry within the healthcare, insurance or government sector

Preferred Technical and Professional Expertise
  • Prior experience working collaboratively with health care providers is strongly preferred.
  • Experience with health care claims and/or health care fraud/program integrity
  • Knowledge of health care claims and/or health care fraud/program integrity
  • Additional coding credentials such as RHIT, CCS, or CCS-P highly preferred.
  • Medical record review experience and/or clinical background such as RN or LPN
  • Experience in Excel, preparing graphs, trending data, and conducting presentations strongly preferred.

About Business Unit
IBM Watson Health is pioneering a new partnership between humanity and technology with the goal of transforming global health and revolutionizing many aspects of the medical and pharmaceutical industries, as well as government sectors. We aspire to improve lives and give hope by delivering innovation to address the worlds most pressing health challenges through data and artificial intelligence insights.

Your Life @ IBM
What matters to you when youre looking for your next career challenge?

Maybe you want to get involved in work that really changes the world? What about somewhere with incredible and diverse career and development opportunities where you can truly discover your passion? Are you looking for a culture of openness, collaboration and trust where everyone has a voice? What about all of these? If so, then IBM could be your next career challenge. Join us, not to do something better, but to attempt things you never thought possible.

Impact. Inclusion. Infinite Experiences. Do your best work ever.

About IBM
IBMs greatest invention is the IBMer. We believe that progress is made through progressive thinking, progressive leadership, progressive policy and progressive action. IBMers believe that the application of intelligence, reason and science can improve business, society and the human condition. Restlessly reinventing since 1911, we are the largest technology and consulting employer in the world, with more than 380,000 IBMers serving clients in 170 countries.

Location Statement
IBM will not be providing visa sponsorship for this position now or in the future. Therefore, in order to be considered for this position, you must have the ability to work without a need for current or future visa sponsorship.

Being You @ IBM
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.



  • Computers Software and Hardware
Posted: 2019-10-24 Expires: 2019-11-23

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Watson Health - Business Analyst - Claims Investigator

Des Moines, IA 50309

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