Senior Consultant Job Durham area,North Carolina USA,Healthcare

HM

Note:

The client is specifically looking for resources with extensive Facets experience, particularly around DME claims and authorizations.

Must Have's

Experience implementing Medicare LOB on Facets platform

Knowledge of CMS regulatory guidelines/policies and ability to relate that to Facets capability to administer those guidelines/policies

Payment Integrity

Payment Operations and Payment Integrity Work streams

Implement a process to test end-to-end common Medicare Advantage leakage scenarios across multiple Medicare service categories to rapidly determine whether any common issues are relevant at Client NC. Provide recommendations on priority focus areas based on prior leakage experience. This assumes tiger teams will implement end-to-end fixes for authorization-to-claim matching and the lesser-of rules across all Medicare services.

MOOP Accumulator Accuracy (Part C only) If the system triggers $0 prematurely, the plan absorbs avoidable medical cost. Test that MOOP applies only after the precise allowed in network Part A/B amounts are reached.

No Surprises Act (NSA) – Ensure Not Over Applying Protections NSA requires in network cost share only for certain emergency and facility based OON care. Over broad application causes the plan to pay unnecessarily high amounts. Validate correct identification of true NSA qualifying claims.

Hospice Carve Out Enforcement Hospice related care should shift to Medicare FFS. MA plans frequently overpay hospice related inpatient, DME, labs, or drugs. Test routing of claims during hospice election and unrelated services rules.

MSP (Medicare Secondary Payer) Primacy Enforcement A top source of preventable over payment. Validate correct primacy for GHP, liability/no fault, workers comp, black lung, and injury related services.

Accurate Encounter Data for Risk Adjustment Revenue Missing or rejected encounters reduce RAF revenue and increase effective medical cost ratio. Validate 837I/837P end to end acceptance and error correction.

NCCI / MUE Edits Enforcement Missing NCCI edits = duplicate, unbundled, or medically unlikely payments. Ensure correct quarterly versioning and modifier logic.

Provider Contract Rate & Fee Schedule Accuracy Post Migration Incorrect rates = systematic over payment. Validate DRG, APC, SNF per diem, home health per visit, therapy fee schedules, and carve outs.

Prior Authorization (PA) Enforcement & Denial Integrity Validate PA requirement checks, denial codes, retro PA, and overturned appeal flows.

Admit Date Payer Responsibility (Inpatient Stays) MA should not pay for inpatient stays where the beneficiary enrolled after admission or moved to hospice mid stay.

Home Health Cost Share & Coverage Rules HH utilization spikes after migration if edits or coverage rules malfunction. Test visit limits, OON logic, and cost share amounts tied to D SNP 2026 PPO constraints.

Inpatient Outlier, Transfers, & DRG Weight Calculation Improper DRG Configuration or missing transfer logic leads to massive over payment.

ER vs Urgent Care vs Observation Status Accuracy Upcoding urgent care to ER creates large avoidable expense. Validate POS, revenue codes, and observation hours. NSA adds complexity for true emergencies.

Duplicate & Corrected Claim Management Plans lose millions annually on duplicate outpatient, professional, or inpatient corrected claims. Validate DCN/ICN matching, timely filing, and automated duplicate denial logic.

Coverage Policy Denials (NCD/LCD) Missing coverage rules lead to payment of non covered, experimental, or medically unnecessary services.

Emergency Stabilization vs Post Stabilization OON Billing Incorrectly paying OON post stabilization care as emergency inflates spend. NSA defines the emergency portion only.

Chiropractic, PT/OT/ST Visit Limits & Medical Necessity Therapy categories are high leakage areas. Validate annual limits, frequency edits, and NCCI bundling logic.

Radiation, Imaging, and Bundling Logic CT/MRI/PET are NCCI-heavy zones prone to over payment if edits aren't firing.

Ambulance Transport Coverage & OON Rules Ground ambulance is not covered under NSA; improper OON approvals cause over payment. Validate medical necessity, mileage, and…